amerihealth-caritas/finops/amerihealth-caritas-finops.yml at main · api-evangelist/amerihealth-caritas · GitHub

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specification: FinOps Framework
specificationVersion: '1.0'
schema: https://www.finops.org/framework/
provider: AmeriHealth Caritas
providerId: amerihealth-caritas
created: '2026-05-23'
modified: '2026-05-23'
reconciled: true
tags:
  - FinOps
  - FOCUS
  - FHIR
  - Healthcare
  - CMS
  - Medicaid
  - Patient Access
description: >-
  FOCUS-aligned FinOps for the AmeriHealth Caritas FHIR APIs:
  regulatory free access (no vendor invoice). The cost surface is the
  consumer's own infrastructure (request volume, data egress, identity
  / consent flow, member outreach) rather than per-call API charges
  from AmeriHealth Caritas. This FinOps file does not attempt to model
  the underlying health-plan economics (Medicaid capitation, premiums,
  D-SNP MA payments, PerformRx PBM revenue) — those are commercial
  contracts with state Medicaid agencies, CMS, employers, and pharmacy
  clients rather than API-level charges.
sources:
  - https://developer.amerihealthcaritas.com/
  - https://developer.amerihealthcaritas.com/dvp/v1/apiadditionaldocsinfo/
  - https://www.cms.gov/priorities/key-initiatives/burden-reduction/interoperability
alignedWith:
  framework: FinOps Foundation Framework
  frameworkUrl: https://www.finops.org/framework/
  dataSpec: FOCUS
  dataSpecVersion: '1.3'
  dataSpecUrl: https://focus.finops.org/focus-specification/v1-3/
publisherName: AmeriHealth Caritas
serviceCategory: Healthcare Interoperability
billingModel:
  pricingCategory: Regulatory Free Access (no fee)
  billingFrequency: N/A
  billingCurrency: USD
  chargeCategories:
    - Usage
focusColumns:
  ServiceName: AmeriHealth Caritas FHIR APIs
  ServiceCategory: Healthcare Interoperability
  ProviderName: AmeriHealth Caritas
  PublisherName: AmeriHealth Caritas
  InvoiceIssuerName: N/A (no AmeriHealth Caritas invoice for API access)
  BillingCurrency: USD
  ChargeCategory: Usage
meters:
  - name: patient_access_requests
    description: Member-authorized FHIR R4 queries against Patient Access endpoints; not billed but tracked for capacity and rate-limit purposes.
    unit: request
    aggregation: sum
    dimensions:
      - plan_code
      - resource_type
      - app
  - name: provider_directory_requests
    description: Public Provider Directory FHIR queries.
    unit: request
    aggregation: sum
    dimensions:
      - plan_code
      - resource_type
      - app
  - name: drug_formulary_requests
    description: Public Drug Formulary FHIR queries (MedicationKnowledge / List).
    unit: request
    aggregation: sum
    dimensions:
      - resource_type
      - app
  - name: oauth_member_authorizations
    description: SMART on FHIR consent flows initiated and completed; useful for measuring application activation.
    unit: authorization
    aggregation: sum
    dimensions:
      - plan_code
      - app
  - name: refresh_token_uses
    description: OAuth refresh token exchanges; useful for understanding member retention in the app.
    unit: exchange
    aggregation: sum
    dimensions:
      - plan_code
      - app
  - name: data_egress
    description: PHI / FHIR resource bytes returned to the consumer; informs the consumer's own storage and processing cost.
    unit: GB
    aggregation: sum
    dimensions:
      - plan_code
      - resource_type
      - app
principles:
  - name: Visibility
    description: >-
      AmeriHealth Caritas does not invoice for API access. Track
      request and member-authorization volumes via your application's
      own logging (token issuance, FHIR request audit). Reconcile
      against the per-plan CapabilityStatement at
      /{planCode}/{api}/metadata.
  - name: Allocation
    description: >-
      Tag FHIR requests with the originating product feature (member
      portal, claims explorer, care management workflow, formulary
      lookup) AND with the plan code so downstream cost can be
      allocated by both feature and population.
  - name: Optimization
    description: >-
      Use _summary and _elements parameters to reduce payload size and
      downstream egress cost. Cache Provider Directory and Drug
      Formulary responses aggressively — they do not require member
      consent and change infrequently. Use bulk-data ($export)
      operations when supported to amortize request overhead.
  - name: Accountability
    description: >-
      API access is free but operational risk is real: mishandled
      member PHI triggers HIPAA exposure. Establish clear data-
      retention windows and a periodic audit of which member tokens
      are still active. Honor member consent revocation immediately
      and rotate any compromised Client Secrets through the developer
      portal.
maintainers:
  - FN: Kin Lane
    email: kin@apievangelist.com