PayerGraphDocs
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Getting started

Introduction

PayerGraph is an API for payer-policy intelligence. It converts fragmented payer policies, medical-necessity criteria and prior-authorization rules into structured, versioned, source-backed data that your product can query programmatically.

PayerGraph does not submit prior authorizations or track payer decisions—it is the intelligence layer your workflow integrates. You send a payer, plan, geography and medical codes; you receive normalized JSON with citations back to the source policy.

Quickstart →
Make your first code check in five minutes.
API Reference →
Every endpoint, parameter and response schema.
Core concepts →
How payers, plans, policies and codes relate.

Quickstart

Check whether a CPT code requires prior authorization under a specific plan. All examples use sandbox data.

Authentication

Authenticate every request with a bearer token in the Authorization header. Keys are issued per environment and can be rotated from your dashboard.

Authorization: Bearer pg_sandbox_xxxxxxxxxxxx
Keep keys server-side. Never expose API keys in browser code or mobile builds—proxy PayerGraph calls through your backend.

Environments

EnvironmentBase URLNotes
Sandboxsandbox.payergraph.comSandbox example data for integration testing.
Productionapi.payergraph.comLive policy data. Keys begin with pg_live_.

Making your first request

  1. Get a sandbox key from your PayerGraph dashboard.
  2. Call POST /v1/codes/check with a payer, state and CPT code.
  3. Inspect coverage_status, prior_authorization and policy_sources in the response.
  4. Follow a policy_id into the policy and medical-necessity endpoints.

Core concepts

The PayerGraph data model follows one chain: Payer → Plan → Policy → Code → Requirement → Source.

Payers

The insurance organizations whose rules PayerGraph structures. Each payer is a stable entity with an ID, aliases and associated plans.

Plans and lines of business

A payer offers plans across commercial, Medicare Advantage and Medicaid managed care. Rules frequently differ between them.

Policies

Versioned medical policies, prior-auth lists and clinical guidelines parsed into structured rules with effective dates.

Medical codes

CPT, HCPCS and ICD-10 codes are the join keys between your workflow and payer rules.

Coverage determinations

The structured answer to “is this covered?”: covered, covered_with_conditions, not_covered or unknown—always with cited sources.

Prior-authorization requirements

Per code and plan: required, not_required, conditional or unknown, with the list version that says so.

Medical-necessity criteria

Clinical criteria parsed into a logic tree that preserves the original AND/OR structure alongside the source text.

Policy sources and versions

Every rule points at a source document, effective date and retrieval timestamp. Superseded versions remain queryable.

Confidence and limitations

Every determination carries a confidence level. Low-confidence and conflicting extractions are flagged, not hidden—treat unknown as unknown.

Guides

Checking a code →
Answer coverage and prior-auth for a code.
Searching policies →
Query by payer, state, code or concept.
Retrieving necessity criteria →
Fetch criteria trees with sources.
Processing codes in batches →
Check up to 500 codes per request.
Monitoring policy changes →
Poll structured change events.
Configuring webhooks →
Push change events to your endpoint.
Handling uncertain results →
Design UX for honest uncertainty.