Enhanced Eligibility

A: Some payers require 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.

You send the National Provider Identifier (NPI) in all Eligibility requests. Each NPI to be sent in Eligibility requests may need enrollment. 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.

A: The Enhanced Eligibility API extends the functionality of Optum’s 270/271 json-based Eligibility API by offering value-add functionality that aims to improve response accuracy and quality. The value-add functionality is made available through a customer specific Rules Engine that takes data about the submitter and enhances transactions in real-time. This functionality alleviates the need for RCM specialists to track Eligibility specific intelligence offline, handle payer-specific response deviations, and will save your operation time and money. In addition, the Enhanced Eligibility API offers integrated Self Pay Detection to providers that need to verify a patient’s uninsured status which will result in a reduction of bad debt and increased collections. The Enhanced Eligibility API offers the same depth in payer connections, network stability, support, and rapid response times that Optum customers are familiar with and adds proven automation to help providers get the most out of real-time Eligibility verification.

A: We do! You can use our Sandbox environment even before signing a contract. It requires a separate set of secure credentials which you can obtain 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 such as Postman, or test APIs using your own development console.