# Validate claim coverage risk
URL: https://backworkhealth.com/docs/api/validateClaim

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**

```bash
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`)

```json
{
  "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
  }
}
```