Supergood | CoverageToolkit API
Programmatically access payer coverage policies, prior authorization criteria, medical necessity rules, coding guidance, and plan-level benefits from CoverageToolkit with a stable REST API. Supergood builds and operates production-grade, unofficial CoverageToolkit integrations so your team can automate coverage checks and revenue cycle workflows without heavy custom engineering.
CoverageToolkit is a resource used across healthcare to centralize insurance coverage information—think payer policies, utilization management criteria, documentation requirements, and coding rules for services and drugs. With an unofficial API, you could look up whether a procedure is covered by a specific plan, determine if prior authorization is required, retrieve the documentation checklist and submission channels, and track policy updates by payer and state.
If you're a healthcare tech startup in billing, practice management, or provider services, integrating your stack with CoverageToolkit unlocks concrete data flows and features:
- Pull: Payer policies, plan benefits, prior auth criteria, coverage status (covered/excluded/conditional), documentation requirements, coding/modifier guidance, site-of-care rules, update histories
- Push: Watchlists of services/drugs to monitor, saved payer-policy links for staff, annotations and internal notes, alerts routed to care coordination, prefilled auth checklists for intake teams
- Build: Authorization-aware scheduling, automated coverage checks in patient access, denial prevention and appeal packet generation, coding compliance helpers, payer policy dashboards for RCM
What is CoverageToolkit?
CoverageToolkit aggregates coverage policies and benefit information across commercial insurers, Medicaid programs, and Medicare Advantage plans. It organizes payer rules around medical necessity, prior authorization, step therapy, site-of-care restrictions, documentation checklists, and coding requirements for services, procedures, and pharmaceuticals.
Core product areas include:
- Coverage policies (medical, pharmacy) with linked PDFs and criteria
- Prior authorization requirements and submission guidance
- Coding, modifiers, and place-of-service rules
- Plan/benefit summaries by payer, product, and state
- Policy update tracking and change summaries
- Appeals timelines and references to regulatory guidance
Common data entities:
- Payers and Plans (state, product, network)
- Policies (medical, pharmacy) with coverage status
- Services/Procedures (CPT/HCPCS) and Diagnoses (ICD-10)
- Drugs (NDC, HCPCS J-codes)
- Authorization Requirements (criteria, attachments, channels)
- Documentation Checklists (clinical notes, labs, imaging, forms)
- Site-of-Care and Step Therapy rules
- Appeals and Timelines (internal/external review references)
The CoverageToolkit Integration Challenge
Organizations rely on CoverageToolkit and payer documentation daily, but transforming portal and PDF-driven coverage research into automated workflows is hard:
- Fragmented formats: Policies live in PDFs, web pages, and plan brochures with inconsistent structure
- Payer- and state-specific nuances: Criteria and submission channels vary by product, state, and line of business
- Update cadence: Policies change frequently, and subtle revisions matter for compliance
- Terminology drift: Equivalent services may be described differently across payers and plans
- Linking to operations: Intake, scheduling, coding, and RCM teams need actionable, structured outputs aligned with patient and visit data
How Supergood Creates CoverageToolkit APIs
Supergood reverse-engineers authenticated browser flows, policy search navigation, and document retrieval to deliver a resilient API endpoint layer.
- Handles public access, credentialed logins, and SSO/OAuth where applicable
- Extracts and normalizes policy content from PDFs and HTML, preserving citations
- Harmonizes service/drug identifiers (CPT/HCPCS, ICD-10, NDC, J-codes) and maps to payer-specific rules
- Tracks policy versions and publishes change detection along with effective dates
- Aligns with customer entitlements and usage constraints to ensure compliant access
Use Cases
Authorization-Aware Scheduling and Eligibility
- Validate coverage and prior auth requirements before scheduling a visit or ordering a service
- Respect site-of-care and frequency limits to avoid downstream denials
- Surface documentation checklists to front-office and intake teams
Prior Authorization Automation
- Pre-screen requests with payer criteria and build submission packets automatically
- Route to the correct channels (payer portal, fax, EDI) with required attachments
- Track turnaround times and escalate if criteria or timelines change
Denial Prevention and Appeals
- Cross-reference denials with current policy language and coverage status
- Generate appeal letters with policy citations and supporting documentation lists
- Monitor updates to policies that impact ongoing appeals
Coding Compliance and Intake Guidance
- Map CPT/HCPCS codes, modifiers, and place-of-service rules by payer and plan
- Ensure units, frequency, and documentation match payer expectations
- Standardize guidance across clinics and provider groups
Available Endpoints
Authentication
POST /sessions: Establish a session using credentials where applicable. Supergood manages MFA (SMS, email, TOTP) and SSO/OAuth when enabled. Returns a short-lived auth token maintained by the platform.
curl --request POST \
--url https://api.supergood.ai/integrations/<integration_id>/sessions \
--header 'Authorization: Basic <Base64 encoded token>' \
--header 'Content-Type: application/json' \
--data '{
"username": "[email protected]",
"password": "<password>",
"mfa": {
"type": "totp",
"code": "123456"
}
}'
Example response
{
"authToken": "eyJhbGciOi...",
"expiresIn": 3600,
"user": {
"id": "u_91d2f3",
"name": "Coverage Ops",
"entitlements": ["policies", "plans", "auth_requirements"]
}
}
Coverage Policies
GET /coverage/policies: Retrieve payer policy records and coverage determinations for services and drugs. Use this to decide if a service is covered and whether prior authorization or documentation is required.
Query parameters
- payerId: string
- planId: string
- state: string (ISO 3166-2)
- serviceCode: string (CPT/HCPCS)
- ndc: string (drug NDC)
- diagnosisCode: string (ICD-10)
- activeOn: ISO 8601 date
Example response
{
"items": [
{
"policyId": "pol_3f9a21",
"title": "Knee Arthroscopy (CPT 29870-29889) Coverage",
"payerId": "payer_acme-health",
"planId": "plan_acme-oh-hmo",
"state": "US-OH",
"coverageStatus": "conditional",
"priorAuthorizationRequired": true,
"siteOfCare": "outpatient_hospital_or_asc",
"frequencyLimits": {"units": 1, "period": "per_12_months"},
"criteriaSummary": [
"Conservative therapy tried and failed",
"Imaging confirms pathology",
"Functional impairment documented"
],
"documentationRequirements": [
{"type": "clinical_notes", "description": "Orthopedic assessment within 60 days"},
{"type": "imaging_report", "description": "MRI or X-ray supporting diagnosis"}
],
"effectiveDate": "2026-01-01",
"lastUpdated": "2026-01-14",
"policyUrl": "https://coveragetoolkit.org/policies/acme/knee-arthroscopy.pdf"
}
],
"page": 1,
"pageSize": 50,
"total": 1
}
Plans and Benefits
GET /payers/plans: List payer plans with product type, state coverage, and utilization management details. Use this to route requests to the correct plan and understand benefit nuances.
Query parameters
- payerId: string
- state: string (ISO 3166-2)
- productType: string (HMO, PPO, EPO, MA, Medicaid)
- activeOn: ISO 8601 date
Example response
{
"items": [
{
"planId": "plan_acme-oh-hmo",
"name": "Acme Health Ohio HMO",
"payerId": "payer_acme-health",
"state": "US-OH",
"productType": "HMO",
"network": "in_network_only",
"umVendor": {"name": "UMCo", "portal": "https://umco.example/portal"},
"effectiveStart": "2025-10-01",
"effectiveEnd": null,
"submissionChannels": ["portal", "fax"],
"notes": "Requires site-of-care review for select infusions"
}
],
"page": 1,
"pageSize": 100,
"total": 1
}
Prior Authorization Requirements
POST /authorizations/requirements: Evaluate whether prior authorization is required and return the criteria, required fields, and supported submission channels for a given service/drug and plan context.
curl --request POST \
--url https://api.supergood.ai/integrations/<integration_id>/authorizations/requirements \
--header 'Authorization: Bearer <authToken>' \
--header 'Content-Type: application/json' \
--data '{
"payerId": "payer_acme-health",
"planId": "plan_acme-oh-hmo",
"serviceCode": "29881",
"diagnosisCode": "M23.221",
"placeOfService": "22",
"performingProvider": {"npi": "1234567890", "taxonomy": "Orthopedic Surgery"},
"member": {"id": "mem_9b42f0", "dob": "1984-08-12"},
"dateOfService": "2026-01-19"
}'
Example response
{
"priorAuthorizationRequired": true,
"coverageStatus": "conditional",
"criteria": [
{"id": "crit_1", "text": "Document failed conservative therapy >= 6 weeks"},
{"id": "crit_2", "text": "Imaging confirms meniscal tear"}
],
"requiredFields": [
{"name": "clinical_notes", "type": "document"},
{"name": "imaging_report", "type": "document"},
{"name": "procedure_code", "type": "string", "value": "29881"}
],
"attachments": ["clinical_notes", "imaging_report"],
"submissionChannels": ["portal", "fax"],
"turnaroundTimeDays": 7,
"policyRefs": [
{"policyId": "pol_3f9a21", "section": "Medical Necessity Criteria"}
]
}
Appeal Packet Generator
POST /appeals/packets: Construct a payer-specific appeal packet from a denial reason, relevant policy citations, and available documentation. Returns a templated letter and checklist for internal review.
curl --request POST \
--url https://api.supergood.ai/integrations/<integration_id>/appeals/packets \
--header 'Authorization: Bearer <authToken>' \
--header 'Content-Type: application/json' \
--data '{
"payerId": "payer_acme-health",
"planId": "plan_acme-oh-hmo",
"denial": {
"code": "PR-50",
"reason": "Medical necessity",
"serviceCode": "29881",
"date": "2026-01-21"
},
"member": {"id": "mem_9b42f0", "name": "Jordan Patel"},
"provider": {"npi": "1234567890", "name": "BrightCare Ortho"},
"supportingDocs": ["clinical_notes", "imaging_report"]
}'
Example response
{
"appealId": "apl_71af2b",
"status": "draft",
"letter": {
"format": "pdf",
"size": 204812,
"downloadUrl": "https://download.coverage.example/signed/abc123..."
},
"checklist": [
{"item": "Include orthopedic assessment within 60 days"},
{"item": "Attach MRI report confirming diagnosis"}
],
"policyCitations": [
{"policyId": "pol_3f9a21", "sections": ["Medical Necessity", "Documentation"]}
],
"createdAt": "2026-01-21T16:05:42Z",
"referenceId": "appeal-batch-jan21"
}
Technical Specifications
- Authentication: Public content and/or username/password with MFA (SMS, email, TOTP) and SSO/OAuth where enabled; supports service accounts or customer-managed credentials
- Response format: JSON with consistent resource schemas and pagination
- Rate limits: Tuned for enterprise throughput while honoring site usage controls
- Session management: Automatic reauth and cookie/session rotation with health checks
- Data freshness: Near real-time retrieval of policies, plans, and criteria with version tracking
- Security: Encrypted transport, scoped tokens, and audit logging; respects CoverageToolkit entitlements and usage requirements
- Webhooks: Optional asynchronous delivery for policy updates, criteria changes, and watchlist alerts
Performance Characteristics
- Latency: Sub-second responses for list/detail queries under normal load
- Throughput: Designed for high-volume coverage checks and authorization evaluations
- Reliability: Retry logic, backoff, and idempotency keys minimize duplicate actions
- Adaptation: Continuous monitoring for site changes and new policy versions with rapid adapter updates
Getting Started
- Schedule Integration Assessment
Book a 30-minute session to confirm your CoverageToolkit usage patterns, target payers/plans, and authentication model.
- Supergood Builds and Validates Your API
We deliver a hardened CoverageToolkit adapter tailored to your workflows and entitlements.
- Deploy with Monitoring
Go live with continuous monitoring and automatic adjustments as CoverageToolkit evolves.
Frequently Asked Questions
Q: Which CoverageToolkit areas can this integration cover?
Supergood supports workflows across commonly used CoverageToolkit resources (coverage policies, prior auth criteria, plan benefits, coding guidance), subject to your entitlements. We scope coverage during integration assessment.
Q: How are PDFs, dynamic pages, and policy updates handled?
We parse HTML/PDF content into structured JSON, preserve citations, and version policies. Our adapters detect changes and publish diffs so teams can respond to updates quickly.
Q: Can I use this to prevent denials and automate appeals?
Yes. You can embed coverage and documentation checks upstream, and generate appeal packets with policy citations when denials occur. Webhooks can alert teams to criteria updates mid-cycle.
Q: Will this integrate with my EHR or practice management system?
Supergood provides normalized endpoints and can connect via your existing middleware, queues, or APIs. Many customers embed coverage checks into intake, scheduling, and RCM workflows alongside EHR data.
Related Integrations
Availity API - Programmatically access payer portals and eligibility with Supergood
Ready to automate your CoverageToolkit workflows?
Supergood can have your CoverageToolkit integration live in days with no ongoing engineering maintenance.
