The Optum difference
Efficient connectivity that works
Easily connect your payers and providers through the Optum Intelligent Health Care Network™, the largest in the U.S. Our APIs handle complex transactions behind-the-scenes and make JSON data human-readable. Plus, check claim status across hundreds of payers in real time.
Unparalleled accuracy
Integrate with PMS or use portal-based solutions to file claims more accurately and shorten the time to get paid.
Healthcare expertise
Other mass marketplaces sell generic, one-size-fits-all products. We specialize in healthcare, so Optum solutions are designed exactly for your needs. And you can rest assured that they are state of the art and compliance is always top of mind.
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Our revenue cycle APIs
Eligibility API
This API manages the X12 standards behind the scenes and gives you instant access to medical subscriber or dependent plan membership, copays, coinsurances, deductibles and more in a simple, human-readable format.
Enhanced Eligibility API
This solution builds on the existing 270/271 JSON-based API, delivering advanced features that boost response accuracy and quality. Our customer-specific rules engine uses submitter data to refine transactions in real time, eliminating manual tracking and saving considerable time.
Prior Authorization Inquiry API
This time-saving API checks authorization status in real time so clinical staff can respond early before a patient’s appointment. It connects EDI, web portal payers and utilization management vendors. It can receive a request in JSON or EDI-X12 and return it in the same format.
Claims Status API
Translate the X12 EDI 276 transaction to JSON, making it easier for developers to integrate into users’ applications. See the reasons a claim is denied or rejected. Plus get EDI-to-JSON mapping documentation, so you can quickly find the EDI segments and loops that map to each JSON attribute in the API.
Claims Responses and Reports (ERA) API
This API provides a direct connection to your mailbox where payers will send their reports and responses to your claims. See claim payments, claim status updates and other communications in real time.
Institutional Claims API
Before submitting an institutional claim, the Institutional Claims API allows the submitter to run claims through extensive rules and logic to correct potential errors before sending to the payer.
Professional Claims API
Translate the X12 EDI 837P transaction to JSON, making it easier for developers to integrate into users’ applications. This API allows healthcare providers to submit claims for a service or encounter. Plus get EDI-to-JSON mapping documentation, so you can quickly find the EDI segments and loops that map to each JSON attribute in the API.
Attachments API
Quickly get the status on claims and submit additional documents in response in an easy-to-understand format. Find and download attachment documents for payers. You can submit attachments in two ways: solicited and unsolicited.
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Brochure
Optum Medical EDI Network: Simple and secure healthcare transactions
Use advanced APIs to enhance accuracy, reduce errors, and expedite payment processing for healthcare providers. Flawless integration and secure transactions make it easier to manage healthcare data.
Synopsis
Level up eligibility and claim status with our APIs
Learn how to automate benefit verifications and claim status checks with RESTful APIs, reducing development time and administrative costs. Get data in simple JSON format, making integration easy and efficient.
Fact Sheet
Transform your business with our medical network APIs
Connect financial, clinical, and engagement solutions with direct mailbox connections and JSON translations of X12 EDI transactions. Access claim payments and eligibility verification to improve your efficiency and boost claim submission rates.
Q: Is there a way to see the JSON mapping or get some insight into EDI – JSON translations?
A: We provide JSON-to-EDI mapping documentation, so you can quickly find out the EDI segments and loops that map to each JSON attribute in the API. Utilize the Developer’s Portal, a free resource for our technical documentation. The link to the JSON-to-EDI mapping can be found here.
Q: Do you have a sandbox that I can test before signing a contract?
A: Yes, we do. Please sign up here for a sandbox test environment to familiarize yourself with our APIs without signing a contract without any financial obligations. For more information, see API testing environments. We provide a list of predefined fields and values for sandbox that you can use for testing a variety of responses by using API URLs and endpoints.
Sandbox Request
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