UnitedHealthcare · Capability

UnitedHealthcare Provider Operations

Workflow capability for healthcare providers using UnitedHealthcare APIs to verify member eligibility, manage claims, check prior authorizations, and access the provider directory. Supports revenue cycle management, point-of-care eligibility, and clinical workflow automation for practices, hospitals, and health IT systems.

Run with Naftiko UnitedHealthcareHealthcare ProviderEligibilityClaims ManagementPrior AuthorizationRevenue Cycle

What You Can Do

POST
Check eligibility — Check member eligibility.
/v1/eligibility
POST
Check benefit — Check patient benefit details.
/v1/eligibility
POST
Inquire claim — Inquire claim status.
/v1/claims
POST
Check prior auth — Check prior auth requirements.
/v1/prior-auth
GET
Get provider — Get provider demographics.
/v1/providers

MCP Tools

verify-member-eligibility

Verify UnitedHealthcare member eligibility and coverage details at point of care including deductible, copay, and network status.

idempotent
check-patient-benefit

Check patient-specific benefit details for a service code including whether authorization is required and estimated cost-sharing.

idempotent
get-claim-status

Look up UnitedHealthcare claim status, payment details, and denial reasons by claim number or member ID.

idempotent
check-prior-authorization

Determine if prior authorization is required for a procedure and check current authorization status to prevent avoidable denials.

idempotent
find-provider

Search UnitedHealthcare provider directory for in-network physicians and organizations by NPI or state.

read-only

APIs Used

uhc-provider

Capability Spec

provider-operations.yaml Raw ↑ 
naftiko: "1.0.0-alpha1"

info:
  label: "UnitedHealthcare Provider Operations"
  description: >-
    Workflow capability for healthcare providers using UnitedHealthcare APIs to verify
    member eligibility, manage claims, check prior authorizations, and access the provider
    directory. Supports revenue cycle management, point-of-care eligibility, and clinical
    workflow automation for practices, hospitals, and health IT systems.
  tags:
    - UnitedHealthcare
    - Healthcare Provider
    - Eligibility
    - Claims Management
    - Prior Authorization
    - Revenue Cycle
  created: "2026-05-03"
  modified: "2026-05-03"

binds:
  - namespace: env
    keys:
      UHC_BEARER_TOKEN: UHC_BEARER_TOKEN

capability:
  consumes:
    - import: uhc-provider
      location: ./shared/provider-api.yaml

  exposes:
    - type: rest
      port: 8080
      namespace: provider-operations-api
      description: "Unified REST API for UnitedHealthcare provider operations."
      resources:
        - path: /v1/eligibility
          name: eligibility
          description: "Member eligibility verification."
          operations:
            - method: POST
              name: check-eligibility
              description: "Check member eligibility."
              call: "uhc-provider.check-eligibility"
              outputParameters:
                - type: object
                  mapping: "$."
            - method: POST
              name: check-benefit
              description: "Check patient benefit details."
              call: "uhc-provider.check-patient-benefit"
              outputParameters:
                - type: object
                  mapping: "$."
        - path: /v1/claims
          name: claims
          description: "Claims management."
          operations:
            - method: POST
              name: inquire-claim
              description: "Inquire claim status."
              call: "uhc-provider.inquire-claim"
              outputParameters:
                - type: object
                  mapping: "$."
        - path: /v1/prior-auth
          name: prior-auth
          description: "Prior authorization management."
          operations:
            - method: POST
              name: check-prior-auth
              description: "Check prior auth requirements."
              call: "uhc-provider.check-prior-auth"
              outputParameters:
                - type: object
                  mapping: "$."
        - path: /v1/providers
          name: providers
          description: "Provider directory."
          operations:
            - method: GET
              name: get-provider
              description: "Get provider demographics."
              call: "uhc-provider.get-provider-demographics"
              with:
                npi: "rest.npi"
              outputParameters:
                - type: object
                  mapping: "$."

    - type: mcp
      port: 9090
      namespace: provider-operations-mcp
      transport: http
      description: "MCP server for AI-assisted UnitedHealthcare provider operations."
      tools:
        - name: verify-member-eligibility
          description: "Verify UnitedHealthcare member eligibility and coverage details at point of care including deductible, copay, and network status."
          hints:
            readOnly: false
            destructive: false
            idempotent: true
          call: "uhc-provider.check-eligibility"
          outputParameters:
            - type: object
              mapping: "$."
        - name: check-patient-benefit
          description: "Check patient-specific benefit details for a service code including whether authorization is required and estimated cost-sharing."
          hints:
            readOnly: false
            destructive: false
            idempotent: true
          call: "uhc-provider.check-patient-benefit"
          outputParameters:
            - type: object
              mapping: "$."
        - name: get-claim-status
          description: "Look up UnitedHealthcare claim status, payment details, and denial reasons by claim number or member ID."
          hints:
            readOnly: false
            destructive: false
            idempotent: true
          call: "uhc-provider.inquire-claim"
          outputParameters:
            - type: object
              mapping: "$."
        - name: check-prior-authorization
          description: "Determine if prior authorization is required for a procedure and check current authorization status to prevent avoidable denials."
          hints:
            readOnly: false
            destructive: false
            idempotent: true
          call: "uhc-provider.check-prior-auth"
          outputParameters:
            - type: object
              mapping: "$."
        - name: find-provider
          description: "Search UnitedHealthcare provider directory for in-network physicians and organizations by NPI or state."
          hints:
            readOnly: true
            openWorld: true
          call: "uhc-provider.get-provider-demographics"
          with:
            npi: "tools.npi"
            state: "tools.state"
          outputParameters:
            - type: object
              mapping: "$."