The API tocheck claimssubmit prior authssubmit enrollmentsQA intake formscheck claimssubmit prior authssubmit enrollmentscheck claimssubmit prior authssubmit enrollmentsQA intake formscheck claimssubmit prior authssubmit enrollmentson payer portals.

Documentation

A team from world-class institutions

MITY CombinatorWaymoTesla
prior_auth.py
1from simplex import SimplexClient
2
3client = SimplexClient(api_key="sk-...")
4
5result = client.prior_auth.submit(
6    portal="covermymeds",
7    credential_name="cmm_production",
8    type="pharmacy",
9    drug_id="ozempic-2mg",
10    diagnosis_code="E11.9",
11    diagnosis_name="Type 2 diabetes mellitus",
12    plan="UnitedHealthcare",
13    state="TX",
14    patient={
15        "first_name": "Maria",
16        "last_name": "Chen",
17        "dob": "1978-06-21",
18        "member_id": "UHC884712",
19        "address": "4521 Elm Creek Dr, Austin, TX 78749",
20    },
21    provider={
22        "npi": "1234567890",
23        "first_name": "Rachel",
24        "last_name": "Okafor",
25    },
26)
27
28print(result.redirect_url)
29# https://covermymeds.com/pa/abc123
The problem

Simplex handles the pain of payer portal automation for you.

001
Prior Authorization — AvailityStep 3 of 5
!
ICD-10 M17.11 triggered 3 new required questions

Conservative therapy attempted?

Yes — 6 months PT documented

X-ray confirms grade III–IV OA?

Yes — attached radiology report

BMI within surgical threshold?

28.4 — within range
All 3 answered automatically

ICD codes surface questions you haven't seen yet

Diagnosis codes trigger new questions mid form. Not just on drug codes, but payer specific criteria and patient history too. A static automation is brittle and breaks on the next patient.

002
Structured Output — CoverMyMedsFHIR JSON
Mapped 14 portal fields to schema

"resourceType": "ServiceRequest",

"status": "active",

"code": "27447",

"diagnosis": "M17.11",

"authNumber": "PA-2024-88471",

"payer": "Humana",

"approved": true

Structured output ready

Portal answers need to become structured data

Each portal labels fields differently. Turning responses into clean output -- FHIR JSON, internal schemas, EHR fields -- requires mapping form questions and updating them every time a portal changes. Simplex does this automatically.

003
AvailityAvaility
CoverMyMedsCoverMyMeds
CignaCigna
UHCUHC
CarelonCarelon
Simplex
+and more...

Each payer portal is different

Availity, Cigna, Carelon, CoverMyMeds -- every portal has its own UI, session flow, MFA method, and quirks. CAPTCHAs, unexpected popups, and mid-form UI changes mean automation built for one portal breaks on the next.

Have a payer portal or RCM flow we don't support yet?