API

Optum Real APIs for Medical Providers

APIs that enable real-time, automated exchange of eligibility, claims and payment data between providers and payers.

Optum Real gives providers access to patient eligibility, benefit, prior authorization and responsibility data across multiple payers in real time, reducing claim denials and improving the health care experience for patients.

Packages starting as low as

Transparency

With real-time transparency into a patient’s eligibility data and coding validation, providers can improve the patient experience and reduce avoidable claim denials.

Efficiency

Access data across multiple payers through a single integration, relieving administrative burden and improving claim processing workflows.

Administrative cost savings

More accurate claim submission reduces administrative costs and expedites reimbursement.

Included modules

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    Optum Real Pre-Service Eligibility API

    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.

    Developer Portal
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    Optum Real Claim Pre-Check API

    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.

    Developer Portal
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    Optum Real Claim Inquiry API

    With the Real Claim Inquiry API, 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 reconciliation requests and appeals more quickly to help reduce administrative burden.

    Real Claim Inquiry API includes:

    • Claim summaries and details

    • Status at the claim and service level

    • Available actions for reconciliations 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.

    Developer Portal

Developer Resources

Try before subscribe – Request access to sandbox credentials for all Optum Real APIs

API Documentation
Request sandbox
Frequently Asked Questions

Q: Do you have a sandbox that I can test before signing a contract?

A: Yes! We encourage you to use our sandbox environment before signing a contract. The login requires a separate set of credentials that you can get from your Starter Guide. 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 the APIs using your own development console.

Q: Can I subscribe to multiple Real APIs?

A: Yes, you can subscribe to one or more Real APIs. The subscriptions will align to the same set of API credentials whether they are ordered at the same time or not.

Q: What organization name do I use when creating my AI Marketplace account?

A: Please use your employer's organization name listed on the active W-9 form filed with the IRS.

Q: What payers do the Real APIs cover?

A: The Real APIs are currently live with UnitedHealthcare. Additional payers may be added in the future. For a listing of payer ID coverage, for each API, please refer to the Optum Real overview page in the developer portal.

Q: How can I test the Real APIs in a lower environment after subscribing but prior to live implementation within my organization?

A: Sandbox is available use for live and mock data testing. In order to test live data, Optum Real customers follow the instructions below. 

  1. Customers must have purchased an API with status “subscribed” in the AI Marketplace account, please work with API consultant to associate provider TIN(s) before sending live data to sandbox environment.
  2. Customers must use their sandbox credentials to send live data to the sandbox environment for the API purchased.
    At this point, responses will be based on the live data submitted to the sandbox environment as opposed to mock data preloaded to the sandbox environment.
  3. The customer will retain the ability to query mock responses from a sandbox environment by using an optional request header called “environment”. By placing the value “sandbox" in the optional header, the request return mock responses.

Please note: If you requested access to the sandbox prior to purchase, you would use the same set of credentials.  NOTE: Do not submit PHI or PII data in the TRY IT page.

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