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Claims Intelligence APIs

CMS claims data APIs for billing validation, fee schedules, and coverage determination.

Overview

The Claims Intelligence APIs provide programmatic access to CMS claims processing data. These APIs help billing teams, RCM platforms, and prior authorization systems validate claims before submission, reducing denials and rework.

All data is sourced from publicly available CMS datasets:

  • NCCI PTP Edits — Correct Coding Initiative Procedure-to-Procedure edits
  • MUE Limits — Medically Unlikely Edits (maximum units per service)
  • Physician Fee Schedule — RVU values and Medicare payment calculations
  • Coverage Determinations — Local Coverage Determination (LCD) policies

Endpoints

Method Path Description
GET /v1/ncci/validate Validate whether two CPT/HCPCS codes can be billed together
GET /v1/mue/:hcpcs Look up MUE limits for a HCPCS code
POST /v1/mue/_batch Batch MUE lookup (up to 100 codes)
GET /v1/pfs/:hcpcs Look up Physician Fee Schedule / RVU data
POST /v1/pfs/_batch Batch PFS/RVU lookup (up to 100 codes)
GET /v1/coverage/check Check LCD coverage determinations for a HCPCS code

Use Cases

  • Pre-submission validation — Check NCCI edits and MUE limits before submitting claims
  • Fee schedule lookups — Get RVU breakdowns and Medicare payment amounts for procedure codes
  • Coverage checks — Verify whether a procedure has active LCD policies that may require additional documentation
  • Batch processing — Validate entire claim lines in a single request using batch endpoints

Data Sources

Dataset Source Update Frequency
NCCI PTP Edits CMS National Correct Coding Initiative Quarterly
MUE Values CMS Medically Unlikely Edits Quarterly
Physician Fee Schedule CMS PFS/RVU Files Annually (with quarterly updates)
Coverage Determinations CMS Medicare Coverage Database As published

All datasets are public domain — no licensing restrictions on use.

Required Scopes

  • claims.read — All claims intelligence endpoints

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