Coverage Criteria

GET /coverage/criteria

Search coverage criteria across all Medicare policies.

Request

GET /v1/coverage/criteria?q=diabetes&section=indications

Query Parameters

Parameter	Type	Required	Description
`q`	string	Yes	Search query for criteria text
`section`	string	No	Filter by section: `indications`, `limitations`, `documentation`, `frequency`, `other`
`policy_type`	string	No	Filter by type: `LCD`, `Article`, `NCD`, `PayerPolicy`
`jurisdiction`	string	No	Filter by MAC jurisdiction code
`cursor`	string	No	Pagination cursor
`limit`	number	No	Results per page (1-100, default 50)

Response

{
  "success": true,
  "data": [
    {
      "criteria_id": "cb_12345",
      "section": "indications",
      "text": "Diabetic testing supplies are covered for beneficiaries who have been diagnosed with diabetes...",
      "tags": ["diabetes", "testing", "supplies"],
      "requires_manual_review": false,
      "confidence_score": 0.92,
      "policy": {
        "policy_id": "L33345",
        "title": "Diabetic Testing Supplies",
        "policy_type": "LCD",
        "jurisdiction": "JM",
        "effective_date": "2024-01-01"
      }
    }
  ],
  "meta": {
    "pagination": {
      "cursor": "eyJpZCI6MTIzfQ",
      "has_more": true,
      "limit": 50
    },
    "search": {
      "query": "diabetes",
      "section": "indications"
    },
    "filters": {
      "policy_type": null,
      "jurisdiction": null
    }
  }
}

Code Examples

import requests

response = requests.get(
    'https://api.verity.health/v1/coverage/criteria',
    params={
        'q': 'diabetes',
        'section': 'indications',
        'limit': 20
    },
    headers={'Authorization': 'Bearer YOUR_API_KEY'}
)

data = response.json()

for criteria in data['data']:
    print(f"[{criteria['policy']['policy_id']}] {criteria['section']}")
    print(f"  {criteria['text'][:100]}...")

const params = new URLSearchParams({
  q: 'diabetes',
  section: 'indications',
  limit: '20'
});

const response = await fetch(
  `https://api.verity.health/v1/coverage/criteria?${params}`,
  {
    headers: {
      'Authorization': 'Bearer YOUR_API_KEY'
    }
  }
);

const data = await response.json();

for (const criteria of data.data) {
  console.log(`[${criteria.policy.policy_id}] ${criteria.section}: ${criteria.text.slice(0, 100)}...`);
}

curl -X GET "https://api.verity.health/v1/coverage/criteria?q=diabetes&section=indications" \
  -H "Authorization: Bearer YOUR_API_KEY"

Section Types

Section	Description
`indications`	Conditions/situations where coverage applies
`limitations`	Restrictions or exclusions from coverage
`documentation`	Required documentation for claims
`frequency`	Frequency limitations for procedures
`other`	Other criteria that don't fit above categories

GET /jurisdictions

List all MAC (Medicare Administrative Contractor) jurisdictions.

Request

GET /v1/jurisdictions

Response

{
  "success": true,
  "data": [
    {
      "mac_name": "Palmetto GBA",
      "mac_code": "11502",
      "jurisdiction_code": "JM",
      "jurisdiction_name": "Jurisdiction M",
      "states": ["TX", "OK", "NM", "CO", "LA", "AR", "MS"],
      "mac_type": "A/B",
      "website_url": "https://www.palmettogba.com/"
    },
    {
      "mac_name": "Novitas Solutions",
      "mac_code": "12502",
      "jurisdiction_code": "JH",
      "jurisdiction_name": "Jurisdiction H",
      "states": ["PA", "NJ", "DE", "MD", "DC"],
      "mac_type": "A/B",
      "website_url": "https://www.novitas-solutions.com/"
    }
  ],
  "meta": {
    "count": 12,
    "source": "db"
  }
}

Response Fields

Field	Description
`mac_name`	Name of the Medicare Administrative Contractor
`mac_code`	CMS contractor number
`jurisdiction_code`	Jurisdiction identifier (e.g., JM, JH, JK)
`jurisdiction_name`	Full jurisdiction name
`states`	Array of state codes covered
`mac_type`	Type of MAC (A/B, DME, HHH)
`website_url`	Contractor's official website

Code Example

const response = await fetch('https://api.verity.health/v1/jurisdictions', {
  headers: { 'Authorization': 'Bearer YOUR_API_KEY' }
});

const { data: jurisdictions } = await response.json();

// Find jurisdiction for a state
const state = 'TX';
const jurisdiction = jurisdictions.find(j => j.states.includes(state));
console.log(`${state} is in jurisdiction ${jurisdiction.jurisdiction_code} (${jurisdiction.mac_name})`);

Use Cases

State Lookup: Find which MAC covers a specific state
Coverage Comparison: Understand why policies differ by region
Billing: Determine correct contractor for claims submission

Coverage Criteria

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