Backwork
API Reference

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.

Endpoint: POST /api/v1/claim-validation

Availability: Live in production.

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

Run a rule-level, non-PHI pre-submission validation for CPT/HCPCS procedure codes and optional ICD-10 diagnosis/context fields. Returns coverage status, prior-auth requirement, denial risk, and issues that should be resolved before authorization or claim submission. Requires prior authorization checker access.

Parameters

  • X-Idempotency-Key (header): Unique key for idempotent requests (recommended for safe retries). Reusing a key with a different body returns 409.
  • payer (body): Optional payer or policy source label. Non-Medicare payer-specific logic may return explicit gaps.
  • plan_type (body)
  • line_of_business (body): Optional rule-level line of business label.
  • procedure_codes (body, required): CPT or HCPCS procedure codes.
  • diagnosis_codes (body): Optional ICD-10-CM diagnosis codes.
  • modifiers (body): Optional two-character procedure modifiers.
  • state (body): Two-letter US state code for jurisdiction lookup.
  • date_of_service (body): Optional date of service (YYYY-MM-DD) for date-specific coverage and prior authorization rules.
  • site_of_service (body)
  • provider_specialty (body): Optional rule-level provider specialty label.
  • age_category (body)
  • sex_when_policy_relevant (body)

Example request

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

Example response (200)

{
  "success": true,
  "data": {
    "payer": "string",
    "plan_type": "commercial",
    "line_of_business": "string",
    "state": "string",
    "date_of_service": "string",
    "site_of_service": "office",
    "provider_specialty": "string",
    "modifiers": [
      "string"
    ],
    "overall_risk": "low",
    "coverage_status": "covered",
    "prior_auth_required": true,
    "denial_risk": "low",
    "confidence": "high",
    "documentation_requirements": [
      "string"
    ],
    "policy_sources": [
      {
        "source_id": "string",
        "policy_id": "string",
        "title": "string",
        "policy_type": "string",
        "jurisdiction": "string",
        "source_url": "string",
        "effective_date": "string",
        "last_verified_at": "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": []
        }
      }
    ],
    "effective_date": "string",
    "last_verified_at": "string",
    "requires_manual_review": true,
    "known_gaps": [
      "string"
    ],
    "issues": [
      "string"
    ],
    "matched_policies": [
      {
        "source_id": "string",
        "policy_id": "string",
        "title": "string",
        "policy_type": "string",
        "jurisdiction": "string",
        "source_url": "string",
        "effective_date": "string",
        "last_verified_at": "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": []
        }
      }
    ],
    "codes": [
      {
        "code": "string",
        "code_type": "string",
        "description": "string",
        "coverage_status": "covered",
        "prior_auth_required": true,
        "pa_required": true,
        "denial_risk": "low",
        "confidence": "high",
        "documentation_requirements": [
          "string"
        ],
        "policy_sources": [
          {}
        ],
        "effective_date": "string",
        "last_verified_at": "string",
        "requires_manual_review": true,
        "known_gaps": [
          "string"
        ],
        "issues": [
          "string"
        ],
        "policy_count": 0
      }
    ],
    "mac": {
      "name": "string",
      "jurisdiction": "string"
    }
  },
  "meta": {
    "request_id": "string",
    "timestamp": "2026-01-15T10:30:00Z",
    "idempotency_key": "string",
    "cached": true
  }
}
POST
/claim-validation

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). Reusing a key with a different body returns 409.

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/claim-validation" \  -H "Content-Type: application/json" \  -d '{    "procedure_codes": [      "string"    ]  }'
{  "success": true,  "data": {    "payer": "string",    "plan_type": "commercial",    "line_of_business": "string",    "state": "string",    "date_of_service": "string",    "site_of_service": "office",    "provider_specialty": "string",    "modifiers": [      "string"    ],    "overall_risk": "low",    "coverage_status": "covered",    "prior_auth_required": true,    "denial_risk": "low",    "confidence": "high",    "documentation_requirements": [      "string"    ],    "policy_sources": [      {        "source_id": "string",        "policy_id": "string",        "title": "string",        "policy_type": "string",        "jurisdiction": "string",        "source_url": "string",        "effective_date": "string",        "last_verified_at": "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"            }          ]        }      }    ],    "effective_date": "string",    "last_verified_at": "string",    "requires_manual_review": true,    "known_gaps": [      "string"    ],    "issues": [      "string"    ],    "matched_policies": [      {        "source_id": "string",        "policy_id": "string",        "title": "string",        "policy_type": "string",        "jurisdiction": "string",        "source_url": "string",        "effective_date": "string",        "last_verified_at": "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"            }          ]        }      }    ],    "codes": [      {        "code": "string",        "code_type": "string",        "description": "string",        "coverage_status": "covered",        "prior_auth_required": true,        "pa_required": true,        "denial_risk": "low",        "confidence": "high",        "documentation_requirements": [          "string"        ],        "policy_sources": [          {            "source_id": "string",            "policy_id": "string",            "title": "string",            "policy_type": "string",            "jurisdiction": "string",            "source_url": "string",            "effective_date": "string",            "last_verified_at": "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"                }              ]            }          }        ],        "effective_date": "string",        "last_verified_at": "string",        "requires_manual_review": true,        "known_gaps": [          "string"        ],        "issues": [          "string"        ],        "policy_count": 0      }    ],    "mac": {      "name": "string",      "jurisdiction": "string"    }  },  "meta": {    "request_id": "string",    "timestamp": "2019-08-24T14:15:22Z",    "idempotency_key": "string",    "cached": true  }}

Last updated on

Check prior authorization requirements

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

Validate coverage and denial risk

Run a rule-level, non-PHI pre-submission validation for CPT/HCPCS procedure codes, diagnosis codes, payer context, prior-auth requirements, documentation requirements, and denial risk.