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Ancillary Benefits Management APIs for Health Plans

Enabling real-time, automated data exchange between providers, payers and partners.

Support the reduction of the burden of managing ancillary benefits programs separately. Our solutions use an affordability framework to help close care gaps — with capabilities that can lower costs, address inappropriate billing and care and improve patient access.

Achieve better outcomes

Support collaboration between health plans and providers by encouraging care decisions that can help improve clinical outcomes while managing overall costs.

Increase automation

Streamline ancillary benefits management through technology and automation, helping to reduce manual processes and creating a more efficient experience for plans, providers and members.

Close affordability gaps

Help providers make more informed decisions at the point of order and drive policy success by supporting accurate payments, reducing unnecessary services and administrative burden.

Included modules

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    Claims Pre-Pay API

    Integrate policy and reimbursement determinations directly into claims adjudication workflows. This API supports Ancillary Benefits Management products.

    Developer Portal
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    Coverage Requirements Discovery (CRD) API

    Get return responses to CRD queries such as required prior authorization and available Fast Healthcare Interoperability Resources (FHIR) forms, questionnaires and then point to a DTR workflow. This API supports Ancillary Benefits Management products.

    Developer Portal
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    Documentation Templates and Rules (DTR) API

    Retrieve necessary FHIR forms and questionnaires. This API supports Ancillary Benefits Management products.

    Developer Portal
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    Prior Authorization Support (PAS) API

    Use the FHIR Claim and ClaimResponse resources to submit and adjudicate prior authorization requests. This API supports Ancillary Benefits Management products.

    Developer Portal
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    Clinical Order Guidance (COG) API

    Help providers identify the most clinically appropriate service at the point of order or authorization. This API supports genetic laboratory COG for Ancillary Benefits Management products.

    Developer Portal
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    Diagnostic Testing Pricer API

    Get pricing information for diagnostic tests based on health plan policies, fee schedules and supporting reference data. This API supports Ancillary Benefits Management products

    Developer Portal
Related resources
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Taking a holistic approach to affordability

Our Ancillary Benefits Management solutions bring together advanced technology from Optum and our partners to help modernize the ancillary benefits workflows.

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Frequently Asked Questions

Q: What are Ancillary Benefits Management APIs used for?

A:Our Ancillary Benefits Management APIs enable secure, real-time integration between providers, health plans and interoperability partners. They support clinical decision support, prior authorization workflows, policy enforcement, supplier validation and claims adjudication for durable medical equipment (DME) and laboratory & radiology services.

Q: Are the Ancillary Benefits Management APIs available for purchase?

A: Most of our Ancillary Benefits Management (ABM) APIs are offered as part of an integrated solution rather than standalone products. API access is typically included to support connectivity, workflow integration and data exchange for the ABM products your organization has licensed. For more detail about ABM solutions and available capabilities, visit our website or contact your Optum account representative.

Q: Who can use the ABM APIs?

A: These APIs are designed for health plans, health plan interoperability vendors and healthcare technology partners that need to integrate with our ABM solutions and workflows.

Q: How do I connect to the Ancillary Benefits Management APIs?

A: Organizations must complete the onboarding process before accessing the APIs. To get started, visit our website or contact your Optum account representative to discuss connectivity.

Q: How can I test the ABM APIs?

A: Once onboarding is initiated, we will provide access to testing resources, technical documentation and sandbox environments where available.

Q: Do ABM APIs contain protected health information (PHI)?

A: Some APIs may transmit or process protected health information (PHI) as part of clinical, prior authorization or claims-related workflows. All API transactions are governed by strict security, privacy and compliance requirements, with oversight from qualified teams, to protect sensitive healthcare information.

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