API

Pre-Service Claims Inquiry APIs

Centralized and real-time access for claim inquiries to Payers, prior to claim submission.

Access claims processing information through Optum’s centralized API offerings.  Understand and reduce likely denials with an API inquiry before you begin patient treatment. See real-time patient eligibility information, prior authorization requirements, and more in your EHR. Address denials before they occur by doing a claim “pre-check.

API Services include 

  • X12 Validation (HIPAA)
  • Member Eligibility Check
  • COB Check
  • Prior Authorization (PA) Requirements
  • Claim Editing Validation
Additional APIs, Services, and Payers launching soon.
Packages starting as low as

Transparency

Enabling interactions between Providers and Payers. Access real-time inquiries and information across multiple Payers, in one place.

Efficiency

Streamline daily workflows and reduce staff time spent manually retrieving information from various payers

Cost savings

API services can be directly integrated into current workflows, and increased efficiency leads to expedited reimbursement

Included modules

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    X12 Validation (HIPAA)

    Perform OTVM (Online Transaction Validation and Management) Facility service in real-time to validate the 837 X12 claim.

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    Member Eligibility Check

    Check that member has active membership for the date of service.

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    COB Check

    Validate members Coordination of Benefits (COB) information that was provided on the claim.

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    Prior Authorization (PA) Requirements

    Determine if a Prior Authorization is required and status of existing Prior Authorization.

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    Claim Editing Validation

    Code edits and claim validation based on the latest coding guidelines and industry standards.

Developer Resources

Claims Pre Check API

API Documentation
Request sandbox
Frequently Asked Questions

Q: Do you have a sandbox that I can test before signing a contract?

A: Yes, you can use our sandbox environment before signing a contract. The login requires a separate set of credentials that you can get from your Starter Guide. After receiving your client_id and client_secret for our sandbox environment, you can test the API in our interactive documentation, use an application like Postman, or test APIs using your own development console.

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Application Programming Interface

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