API

Eligibility

The Eligibility API uses the standard X12 EDI 270 eligibility transaction, and formats it in JSON for an HTTP request. It makes this popular EDI transaction set more accessible to developers and to users’ applications.

We manage the X12 standards behind the scenes and give you efficient access to medical subscriber or dependent plan membership, copays, coinsurances, deductibles and more in an easy-to-use, human-readable format.

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Up-to-date support

We support a dedicated X12-formatted Eligibility API to send your submission in X12 EDI format. It supports the standard syntax for a complete X12 EDI 270 transaction set.

Thorough

Our Eligibility API solution provides complete patient profiles and benefits information to support healthcare delivery and more efficient and accurate reimbursement.

Efficient reporting, monitoring and audit support

Payers will find claims spend less time in pending status and will see fewer rejected and reworked claims.

Developer resources

Eligibility API

API documentation
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E-book

Reduce staff burden and denials with a 2-stage approach to coverage discovery

An automated, cascading solution that flags no-coverage accounts for deep data queries is the key to producing correct coverage results.

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Frequently Asked Questions

Q: How do I enroll so my payer accepts my eligibility requests?

A: Some payers require National Provider Identifier (NPI) enrollment before they will process eligibility requests and send responses. For the list of payers who require enrollment, please refer to the payer list on ConnectCenter. You will need to log in to access this information.

Depending on the payer, you may need to send the NPI in all Eligibility requests. An office can enroll one NPI and use that NPI for all requests in their office, or they can enroll additional NPIs.

For more information, your Optum implementation analyst will be able to help. 

Q: Can we enroll more than one provider under a single NPI/taxpayer ID? Or will one provider per office work for eligibility under the TIN?

A: Each NPI that will use Eligibility requests requires a separate enrollment. So, there's one NPI per enrollment. The TIN (Taxpayer Identification Number) does not apply, except for its being on the enrollment form. If an office enrolls one NPI, they use that NPI for all requests in that office or they can enroll additional NPIs.

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 Optum representative. 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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