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Python
import requests

url = 'https://api.simplex.sh/pa_fax_get_clinical_questions'
headers = {
    'Authorization': 'Bearer your_api_key_here'
}
params = {
    'icd_code': 'E66.01',
    'drug_name': 'wegovy',
    'bin': '003858',
    'state': 'CA'
}

response = requests.get(url, headers=headers, params=params)
result = response.json()
print(f"LOB: {result['lob_id']} ({result['coverage_status']})")
if result['coverage_status'] == 'resolved':
    for q in result['questions']:
        print(f"{q['id']}: {q['prompt']} [{q['input_type']}]")
        for opt in q.get('options', []):
            print(f"    - {opt}")
{
  "coverage_status": "resolved",
  "icd_code": "<string>",
  "questions": [
    {
      "id": "<string>",
      "prompt": "<string>",
      "input_type": "boolean",
      "units": "<string>",
      "options": [
        "<string>"
      ],
      "depends_on": [
        "<string>"
      ],
      "source": "<string>"
    }
  ],
  "lob_id": "<string>",
  "rationale": "<string>"
}
Returns the clinical questions that must be answered on the prior authorization fax form for a given diagnosis. icd_code is required — it drives the question set. bin, pcn, group, and state are optional but improve the resolver’s accuracy when the payer has plan-specific question variants.
Supply at least one or two of bin, pcn, group, or state alongside icd_code for best results. Without any plan identifiers, the resolver falls back to the default question set for the diagnosis.

Authorizations

​
X-API-Key
string
header
required

Simplex API Key

Query Parameters

​
icd_code
string
required

Exact ICD-10 diagnosis code (e.g. "E11.9"). Drives which clinical question set is returned. Use the Search ICD Codes endpoint to resolve a fuzzy diagnosis first.

​
bin
string

Pharmacy BIN from the patient's insurance card (e.g. "003858"). Optional, but strongly improves resolver accuracy. At least one of bin, pcn, group, or state is recommended.

​
pcn
string

Processor Control Number from the patient's insurance card (e.g. "A4"). Optional.

​
group
string

Group number from the patient's insurance card (e.g. "RXINN01"). Optional.

​
state
string

Two-letter state code where the prescription will be filled (e.g. "CA"). Optional.

​
drug_name
string
required

Drug brand or generic name (e.g. "wegovy", "semaglutide", "zepbound", "mounjaro"). Required — drives which clinical schema is loaded. Matched case-insensitively on substring.

Response

200 - application/json

Get clinical questions response

​
coverage_status
enum<string>
required

resolved: LOB identified, questions rendered. ambiguous: multiple LOBs match — supply more identifiers. not_covered: drug not covered by this LOB. unknown_lob: drug has a schema but no matching LOB. not_attempted: drug_name didn't map to a drug with a clinical schema.

Available options:
resolved,
ambiguous,
not_covered,
unknown_lob,
not_attempted
​
icd_code
string
required

The ICD-10 code the questions were resolved for (echoed from the request).

​
questions
object[]
required

Rendered clinical questions in presentation order. Empty when coverage_status is not resolved.

​
lob_id
string

Resolved line-of-business ID (e.g. "caremark_commercial_2025"). Null when coverage_status is not resolved.

​
rationale
string

Human-readable explanation of the resolution (which LOB won, or why one couldn't be chosen).