Optum Real APIs for Medical Providers

With Real Pre-Service Eligibility, providers can submit real-time eligibility inquiries to payers before the patient’s visit. Through a centralized API, you can access real-time patient eligibility information across multiple payers within your existing EHR system. Spend less time chasing information and more time delivering a high-quality experience for your patients.

Real Pre-Service Eligibility includes:

• Eligibility information including patient demographic information, plan-level cost shares, plan coverage details and insurance details

• Coordination of benefits including primacy and coverage details for each payer plan

• Image of a patient’s insurance ID card

• Provider in- and out-of-network status

Real Pre-Service Eligibility is currently live with UnitedHealthcare. Additional payers are planned for future development. Please visit the developer portal for a list of supported payer IDs.

With Real Claim Pre-Check, providers can submit real-time claim inquiries to payers prior to treatment. Through a centralized API, you can access claim processing information — like eligibility and prior authorization requirements — across multiple payers in real time. This allows you to identify and prevent denials before they occur.

Real Claim Pre-Check includes:

• X12 claim validation (HIPAA)

• Membership coverage eligibility for the date of service

• Coordination of benefits including primacy and coverage details

• Prior authorization requirements and status

• Adherence to payment and medical policies

Real Claim Pre-Check is currently live with UnitedHealthcare. Additional payers are planned for future development. Please visit the developer portal for a list of supported payer IDs.

With Real Claim Inquiry, providers can receive real-time status updates on submitted claims. This centralized API gives you access to claim information — such as summaries, details and status updates — in real time, allowing you to make informed decisions regarding reconsideration requests and appeals more quickly to help reduce administrative burden. 

Real Claim Inquiry includes:

• Claim summaries and details

• Status at the claim and service level

• Available actions for reconsiderations and appeals at the service level

• Download of associated documents

Real Claim Inquiry is currently live with UnitedHealthcare. Additional payers are planned for future development. Please visit the developer portal for a list of supported payer IDs. 

With Real Patient Benefit Check, providers can validate patient benefits as well as prior authorization and referral requirements before care is delivered. This centralized API allows you to reduce denials and give patients clear answers about what’s covered and what they’ll owe before they receive care, reducing surprise bills and improving patient satisfaction.

Real Patient Benefit Check includes:

• Prior authorization requirements and if one already exists for specific service

• Referral requirements and if one already exists for specific service

• Benefits covered by CPT code including limits, restrictions and exceptions*

• Cost share details for in-network and out-of-network services*

*Capability is not currently available and is planned for future release.

Real Patient Benefit Check is currently live with UnitedHealthcare. Additional payers are planned for future development. Please visit the developer portal for a list of supported payer IDs.

With the Real Claim Actions API, providers can submit more accurate claims, reconciliation requests, appeals and supporting documentation. This centralized API gives you access to payer claim processing information in real time to validate claims prior to submission to help identify and prevent likely denials before they occur. It also streamlines and improves the efficiency of the submission process so you can spend less time on administrative tasks and more time with patients.

The Real Claim Actions includes:

• X12 claim validation (HIPAA)

• Membership coverage eligibility for the date of service 

• Coordination of benefits including primacy and coverage details 

• Prior authorization requirements and status 

• Claim submission

• Reconciliation request and appeal submission

• Supporting documentation submission

Real Claim Actions is currently live with UnitedHealthcare. Additional payers are planned for future development. Please visit the developer portal for a list of supported payer IDs.