API

Enhanced Eligibility API

The Enhanced Eligibility API offers value-add coverage discovery that aims to improve response accuracy and quality. 

The Enhanced Eligibility API expands on the existing 270/271 JSON-based API, delivering advanced features designed to boost response accuracy and quality. Our customer-specific rules engine leverages submitter data to refine transactions in real time, allowing you to: 

  • Eliminate manual tracking 
  • Automate payer-specific deviations 
  • Save time and resources 

Comprehensive 

Customers can access a comprehensive database of payer-specific benefit normalization rules. It simplifies the process of obtaining accurate patient benefit data. 

Adaptable  

The Enhanced Eligibility API can be customized to integrate with the customer’s unique workflow requirements through a powerful rules engine. 

Streamlined

Streamline and automate workflows by easily opting in and out of value-added functionality that operates without manual intervention.

Included modules

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    Transaction Deduplication

    Before dispatching your 270 transaction to the clearinghouse, this feature reduces your organization transaction costs by checking previously submitted transactions and retrieving their responses.  

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    Payer Aliasing

    Payer Aliasing creates a mapping between your EHR (electronic health record) or HIS (health information system) Payer ID and the corresponding Optum Payer ID. This allows you to continue using your system's Payer ID for submissions while ensuring accurate identification by Optum.

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    National Provider Identifier (NPI) Management

    This feature automatically applies NPIs to your outgoing transaction request based on the information you include. 

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    Self-Pay Validation

    Medicare MBI Lookup: Demographic data is examined to determine if a patient qualifies for Medicare discovery. Once eligibility is confirmed, it retrieves and displays the patient's MBI number and plan benefits information. 

    Medicaid Coverage Discovery: A patient’s provided insurance coverage is reviewed to determine if they are a candidate for Medicaid discovery. If the patient has Medicaid, the tool presents their plan benefits. 

    HMO Auto-Submit: HMO discovery analyzes the 271 response for data signaling HMO enrollment. The Enhanced Eligibility API then processes a transaction with the HMO payer to determine the patient's eligibility. 

     Commercial Payer Discovery: Optum works with the customer to identify their top payers for coverage discovery. The top payers are then tailored based on the customer's historical transaction volume and provider data. 

Our outcomes
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Case study

Self-scheduling boosts access and reduces staff burden

Learn how ProHealth Physicians transformed their digital experience with online scheduling.

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Case study

Transforming patient experience and revenue cycle

Learn how integrated Optum solutions helped Goshen Health improve patient engagement, staff communication and payment collection.

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Case study

Health system boosts reach with payer channel scheduling

Learn how St. Luke’s Health used an omnichannel patient engagement strategy to expand their reach and reduce no-shows.

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Developer resources

Enhanced Eligibility API

API documentation
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Frequently Asked Questions

Q: What are the differences between the Enhanced Eligibility API and the regular Eligibility API?

  • Custom rules engine: Tailored to each customer, this engine uses submitter data to improve transactions in real time. It reduces the manual effort required to track eligibility intelligence and handle payer-specific response deviations. This saves your operation time and resources.

  • Integrated self-pay detection: This feature helps providers verify a patient's uninsured status, leading to reduced bad debt and increased collections. 

  • Advanced automation: The Enhanced Eligibility API maintains the extensive payer connections, network stability, support and rapid response times that Optum customers expect. It adds advanced automation to optimize real-time eligibility verification. 

Q: What makes the Eligibility API “Enhanced”?

The "enhanced" in Enhanced Eligibility API refers to additional features designed to streamline the complex task of submitting eligibility requests. These include common pre- and post-processing rules that refine the submitted transaction and optimize the returned response. The API is easier to use and more effective, so you don't have to be an expert to get the most out of it.

Q: What makes Enhanced Eligibility a good fit for my organization?

Healthcare data can be inconsistent, and 270/271 EDI contracts often deviate from the standard specification. If your organization struggles with unknown or incomplete patient data, or if you're looking to automate processes to improve your eligibility response rate, the Enhanced Eligibility API is designed to help. It offers advanced features to handle these challenges and streamline your workflow.

Q: Is it possible to opt out of the enhanced features in the Enhanced Eligibility API?

Yes, you can. Our engine primarily interacts directly with the clearinghouse. If you have situations that require robust processing and others that do not, the Enhanced Eligibility API can be tailored to suit your organization's specific requirements.

Q: How can I make sure my payer accepts my eligibility requests?

Some payers need you to enroll your National Provider Identifier (NPI) before they will process eligibility requests and send responses. You'll include your NPI in all eligibility requests. Each NPI you use may need to be enrolled. You can either enroll one NPI for your entire office or enroll multiple NPIs, depending on your needs. 

Q: Do you offer a sandbox environment for testing before signing a contract? 

Yes, we do. Our sandbox environment is accessible even before a contract is signed. You will need to acquire a separate set of secure credentials from your Optum representative. With your client_id and client_secret, you can conduct tests using our interactive documentation, Postman, or your own development console.

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