Backwork
API Reference

Check prior authorization requirements

Evaluate whether procedures require prior authorization based on procedure codes, payer, and state.

Endpoint: POST /api/v1/prior-auth/check

Availability: Live in production.

Authentication: API key in Authorization: Bearer <key> with the read scope.

Evaluate whether procedures require prior authorization based on procedure codes, payer, and state. Without payer (or with payer: Medicare) it answers for traditional Medicare from LCD/NCD policies in the state's MAC jurisdiction; with a payer it answers from that payer's policies. Returns matched policies, coverage disposition, documentation requirements, and clinical criteria. Codes a policy carries only because its title names the drug come back with source: inferred_title_match, cap the confidence, and are named in known_gaps. Send X-Idempotency-Key to replay the first response for safe retries.

Parameters

  • X-Idempotency-Key (header): Unique key for idempotent requests (recommended for safe retries)
  • procedure_codes (body, required): CPT/HCPCS codes to check
  • state (body): Two-letter state code. For Medicare it selects the MAC jurisdiction; for a payer it keeps the payer's policies that apply in that state.
  • payer (body): Payer name, slug or code, e.g. Moda Health, moda-health or MODA. Omit it, or send Medicare, for traditional Medicare LCD, Article and NCD evidence. Any other payer is answered from that payer's own policies.
  • criteria_page (body): Page number for criteria pagination
  • criteria_per_page (body): Items per page for criteria

Code sources: Code entries in the response carry a source: document when the policy document lists the code, inferred_title_match when the code was attached because the policy title names the drug. See Code sources.

Example request

curl -X POST "https://backworkhealth.com/api/v1/prior-auth/check" \
  -H "Authorization: Bearer $BACKWORK_API_KEY" \
  -H "X-Idempotency-Key: $(uuidgen)" \
  -H "Content-Type: application/json" \
  -d '{
  "procedure_codes": [
    "27447"
  ]
}'

Example response (200)

{
  "success": true,
  "data": {
    "pa_required": true,
    "prior_auth_required": true,
    "coverage_status": "covered",
    "confidence": "high",
    "denial_risk": "low",
    "reason": "string",
    "matched_policies": [
      {
        "policy_id": "string",
        "title": "string",
        "policy_type": "string",
        "jurisdiction": "string",
        "source_url": "string",
        "effective_date": "string",
        "last_verified_at": "2026-01-15T10:30:00Z",
        "applicability_scope": "shared_markets",
        "applicability_markets": [
          "string"
        ],
        "applicability_evidence": {
          "document_sha256": "string",
          "market_index_listings": [],
          "document_statements": []
        },
        "applicability_note": "string",
        "public_url": "https://backworkhealth.com/policy/L33831",
        "source_check": {
          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",
          "last_fetched_at": "2026-01-15T10:30:00Z",
          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",
          "source_accuracy": []
        },
        "payer": {
          "name": "string",
          "code": "string",
          "slug": "molina-healthcare"
        },
        "codes": [
          {}
        ]
      }
    ],
    "policy_sources": [
      {
        "source_id": "string",
        "policy_id": "string",
        "title": "string",
        "policy_type": "string",
        "jurisdiction": "string",
        "source_url": "string",
        "effective_date": "string",
        "last_verified_at": "2026-01-15T10:30:00Z",
        "applicability_scope": "shared_markets",
        "applicability_markets": [
          "string"
        ],
        "applicability_evidence": {
          "document_sha256": "string",
          "market_index_listings": [],
          "document_statements": []
        },
        "applicability_note": "string",
        "public_url": "https://backworkhealth.com/policy/L33831",
        "source_check": {
          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",
          "last_fetched_at": "2026-01-15T10:30:00Z",
          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",
          "source_accuracy": []
        },
        "payer": {
          "name": "string",
          "code": "string",
          "slug": "molina-healthcare"
        }
      }
    ],
    "negotiated_rates": {},
    "documentation_checklist": [
      "string"
    ],
    "documentation_requirements": [
      "string"
    ],
    "source_policy_references": [
      {
        "source_id": "string",
        "policy_id": "string",
        "title": "string",
        "policy_type": "string",
        "jurisdiction": "string",
        "source_url": "string",
        "effective_date": "string",
        "last_verified_at": "2026-01-15T10:30:00Z",
        "applicability_scope": "shared_markets",
        "applicability_markets": [
          "string"
        ],
        "applicability_evidence": {
          "document_sha256": "string",
          "market_index_listings": [],
          "document_statements": []
        },
        "applicability_note": "string",
        "public_url": "https://backworkhealth.com/policy/L33831",
        "source_check": {
          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",
          "last_fetched_at": "2026-01-15T10:30:00Z",
          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",
          "source_accuracy": []
        },
        "payer": {
          "name": "string",
          "code": "string",
          "slug": "molina-healthcare"
        }
      }
    ],
    "effective_date": "string",
    "last_verified_at": "2026-01-15T10:30:00Z",
    "requires_manual_review": true,
    "known_gaps": [
      "string"
    ],
    "coverage_decision": {
      "coverage_status": "covered",
      "prior_auth_required": true,
      "documentation_requirements": [
        "string"
      ],
      "denial_risk": "low",
      "policy_sources": [
        {
          "source_id": "string",
          "policy_id": "string",
          "title": "string",
          "policy_type": "string",
          "jurisdiction": "string",
          "source_url": "string",
          "effective_date": "string",
          "last_verified_at": "2026-01-15T10:30:00Z",
          "applicability_scope": "shared_markets",
          "applicability_markets": [],
          "applicability_evidence": {},
          "applicability_note": "string",
          "public_url": "https://backworkhealth.com/policy/L33831",
          "source_check": {},
          "payer": {}
        }
      ],
      "effective_date": "string",
      "last_verified_at": "2026-01-15T10:30:00Z",
      "confidence": "high",
      "requires_manual_review": true,
      "known_gaps": [
        "string"
      ]
    },
    "criteria_details": {
      "indications": [
        {
          "text": "string",
          "tags": [],
          "policy_id": "string"
        }
      ],
      "limitations": [
        {
          "text": "string",
          "tags": [],
          "policy_id": "string"
        }
      ],
      "pagination": {
        "page": 0,
        "per_page": 0,
        "indications": {
          "total": 0,
          "total_pages": 0,
          "has_next": true,
          "has_previous": true
        },
        "limitations": {
          "total": 0,
          "total_pages": 0,
          "has_next": true,
          "has_previous": true
        },
        "documentation": {
          "total": 0,
          "total_pages": 0,
          "has_next": true,
          "has_previous": true
        }
      }
    },
    "mac": {
      "name": "string",
      "jurisdiction": "string",
      "states": [
        "string"
      ]
    }
  },
  "meta": {
    "request_id": "string",
    "timestamp": "2026-01-15T10:30:00Z",
    "idempotency_key": "string",
    "cached": true,
    "attributions": {
      "disclaimer": "string",
      "cpt": "string",
      "loinc": "string",
      "cms": "string",
      "payer_data": "string",
      "negotiated_rates": "string"
    },
    "disclaimer": "string"
  }
}
POST
/prior-auth/check

Authorization

bearerAuth
AuthorizationBearer <token>

API key in format: bwk_live_xxxxx. Keys issued before the rename (vrt_live_) remain valid. bwk_test_ keys work only on the sandbox.

In: header

Header Parameters

X-Idempotency-Key?string

Unique key for idempotent requests (recommended for safe retries)

Request Body

application/json

TypeScript Definitions

Use the request body type in TypeScript.

Response Body

application/json

application/json

application/json

application/json

application/json

application/json

application/json

application/json

application/json

curl -X POST "https://example.com/prior-auth/check" \  -H "Content-Type: application/json" \  -d '{    "procedure_codes": [      "27447"    ]  }'
{  "success": true,  "data": {    "pa_required": true,    "prior_auth_required": true,    "coverage_status": "covered",    "confidence": "high",    "denial_risk": "low",    "reason": "string",    "matched_policies": [      {        "policy_id": "string",        "title": "string",        "policy_type": "string",        "jurisdiction": "string",        "source_url": "string",        "effective_date": "string",        "last_verified_at": "2019-08-24T14:15:22Z",        "applicability_scope": "shared_markets",        "applicability_markets": [          "string"        ],        "applicability_evidence": {          "document_sha256": "string",          "market_index_listings": [            {              "market": "string",              "index_url": "string"            }          ],          "document_statements": [            {              "kind": "non_medicare_disclaimer",              "quote": "string",              "page": 1            }          ]        },        "applicability_note": "string",        "public_url": "https://backworkhealth.com/policy/L33831",        "source_check": {          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",          "last_fetched_at": "2019-08-24T14:15:22Z",          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",          "source_accuracy": [            {              "field": "overall",              "sampled_at": "2019-08-24T14:15:22Z",              "sample_size": 120,              "accuracy": 0.9667,              "ci_low": 0.917,              "ci_high": 0.987,              "method": "manual_review_v1"            }          ]        },        "payer": {          "name": "string",          "code": "string",          "slug": "molina-healthcare"        },        "codes": [          {            "code": "string",            "code_system": "string",            "disposition": "string",            "condition_reference": "string",            "source": "document",            "grounding": "grounded"          }        ]      }    ],    "policy_sources": [      {        "source_id": "string",        "policy_id": "string",        "title": "string",        "policy_type": "string",        "jurisdiction": "string",        "source_url": "string",        "effective_date": "string",        "last_verified_at": "2019-08-24T14:15:22Z",        "applicability_scope": "shared_markets",        "applicability_markets": [          "string"        ],        "applicability_evidence": {          "document_sha256": "string",          "market_index_listings": [            {              "market": "string",              "index_url": "string"            }          ],          "document_statements": [            {              "kind": "non_medicare_disclaimer",              "quote": "string",              "page": 1            }          ]        },        "applicability_note": "string",        "public_url": "https://backworkhealth.com/policy/L33831",        "source_check": {          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",          "last_fetched_at": "2019-08-24T14:15:22Z",          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",          "source_accuracy": [            {              "field": "overall",              "sampled_at": "2019-08-24T14:15:22Z",              "sample_size": 120,              "accuracy": 0.9667,              "ci_low": 0.917,              "ci_high": 0.987,              "method": "manual_review_v1"            }          ]        },        "payer": {          "name": "string",          "code": "string",          "slug": "molina-healthcare"        }      }    ],    "negotiated_rates": {      "property1": {        "min_rate": "string",        "max_rate": "string",        "avg_rate": "string",        "num_rates": 0,        "payer": "string",        "source": "string",        "payer_scope": "string",        "as_of": "string",        "billing_code_set": "string",        "is_current": true      },      "property2": {        "min_rate": "string",        "max_rate": "string",        "avg_rate": "string",        "num_rates": 0,        "payer": "string",        "source": "string",        "payer_scope": "string",        "as_of": "string",        "billing_code_set": "string",        "is_current": true      }    },    "documentation_checklist": [      "string"    ],    "documentation_requirements": [      "string"    ],    "source_policy_references": [      {        "source_id": "string",        "policy_id": "string",        "title": "string",        "policy_type": "string",        "jurisdiction": "string",        "source_url": "string",        "effective_date": "string",        "last_verified_at": "2019-08-24T14:15:22Z",        "applicability_scope": "shared_markets",        "applicability_markets": [          "string"        ],        "applicability_evidence": {          "document_sha256": "string",          "market_index_listings": [            {              "market": "string",              "index_url": "string"            }          ],          "document_statements": [            {              "kind": "non_medicare_disclaimer",              "quote": "string",              "page": 1            }          ]        },        "applicability_note": "string",        "public_url": "https://backworkhealth.com/policy/L33831",        "source_check": {          "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",          "last_fetched_at": "2019-08-24T14:15:22Z",          "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",          "source_accuracy": [            {              "field": "overall",              "sampled_at": "2019-08-24T14:15:22Z",              "sample_size": 120,              "accuracy": 0.9667,              "ci_low": 0.917,              "ci_high": 0.987,              "method": "manual_review_v1"            }          ]        },        "payer": {          "name": "string",          "code": "string",          "slug": "molina-healthcare"        }      }    ],    "effective_date": "string",    "last_verified_at": "2019-08-24T14:15:22Z",    "requires_manual_review": true,    "known_gaps": [      "string"    ],    "coverage_decision": {      "coverage_status": "covered",      "prior_auth_required": true,      "documentation_requirements": [        "string"      ],      "denial_risk": "low",      "policy_sources": [        {          "source_id": "string",          "policy_id": "string",          "title": "string",          "policy_type": "string",          "jurisdiction": "string",          "source_url": "string",          "effective_date": "string",          "last_verified_at": "2019-08-24T14:15:22Z",          "applicability_scope": "shared_markets",          "applicability_markets": [            "string"          ],          "applicability_evidence": {            "document_sha256": "string",            "market_index_listings": [              {                "market": "string",                "index_url": "string"              }            ],            "document_statements": [              {                "kind": "non_medicare_disclaimer",                "quote": "string",                "page": 1              }            ]          },          "applicability_note": "string",          "public_url": "https://backworkhealth.com/policy/L33831",          "source_check": {            "source_url": "https://www.cms.gov/medicare-coverage-database/view/lcd.aspx?lcdid=33831",            "last_fetched_at": "2019-08-24T14:15:22Z",            "content_sha256": "9f86d081884c7d659a2feaa0c55ad015a3bf4f1b2b0b822cd15d6c15b0f00a08",            "source_accuracy": [              {                "field": "overall",                "sampled_at": "2019-08-24T14:15:22Z",                "sample_size": 120,                "accuracy": 0.9667,                "ci_low": 0.917,                "ci_high": 0.987,                "method": "manual_review_v1"              }            ]          },          "payer": {            "name": "string",            "code": "string",            "slug": "molina-healthcare"          }        }      ],      "effective_date": "string",      "last_verified_at": "2019-08-24T14:15:22Z",      "confidence": "high",      "requires_manual_review": true,      "known_gaps": [        "string"      ]    },    "criteria_details": {      "indications": [        {          "text": "string",          "tags": [            "string"          ],          "policy_id": "string"        }      ],      "limitations": [        {          "text": "string",          "tags": [            "string"          ],          "policy_id": "string"        }      ],      "pagination": {        "page": 0,        "per_page": 0,        "indications": {          "total": 0,          "total_pages": 0,          "has_next": true,          "has_previous": true        },        "limitations": {          "total": 0,          "total_pages": 0,          "has_next": true,          "has_previous": true        },        "documentation": {          "total": 0,          "total_pages": 0,          "has_next": true,          "has_previous": true        }      }    },    "mac": {      "name": "string",      "jurisdiction": "string",      "states": [        "string"      ]    }  },  "meta": {    "request_id": "string",    "timestamp": "2019-08-24T14:15:22Z",    "idempotency_key": "string",    "cached": true,    "attributions": {      "disclaimer": "string",      "cpt": "string",      "loinc": "string",      "cms": "string",      "payer_data": "string",      "negotiated_rates": "string"    },    "disclaimer": "string"  }}

Last updated on

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Evaluate an active policy's structured coverage criteria (logic AST) against rule-level parameters.

Validate claim coverage risk

Run a rule-level, non-PHI pre-submission validation for CPT/HCPCS procedure codes and optional ICD-10 diagnosis/context fields.