Overview

Optum's ABM Pre-Pay Claims APIs enable health plans to integrate policy and reimbursement determinations directly into claims adjudication workflows. While each API uses the same core data model, schema, validation rules, and integration patterns, separate endpoints are provided to support the unique business rules, policies, and workflows of specific ABM products.

Common Capabilities Across All Pre-Pay APIs
All ABM Claims Pre-Pay APIs enable health plans to:

• Apply product-specific policy rules during claims adjudication
• Verify whether required prior authorization requirements were met
• Support reimbursement validation and claim pricing workflows
• Incorporate ABM determination data directly into claims processing

Pre-Pay Laboratory API

The Ancillary Benefits Management Pre-Pay Lab API supports Optum's Ancillary Benefit Management (ABM) laboratory products exchange information in real time enabling enforcement of laboratory policies, lab test utilization management and claims management.

Key Use Cases
• Enables policy enforcement during claims adjudication
• Validates whether required authorization was obtained
• Links claims to clinical determinations
• Lab claim pricing at the test-level

Pre-Pay DME API

DME Navigator is a specialized solution within Optum's Ancillary Benefits Management (ABM) portfolio that helps health plans manage the home-medical equipment services. The product connects providers, suppliers, and health plans through an integrated workflow that improves access, ensures clinical appropriateness, and creates more efficient member experience.

Key Use Cases
• Validates whether required authorization was obtained
• Links claims to clinical determinations
• Supplier validation
• Enables policy enforcement during claims adjudication
• DME claim pricing

Pre-Pay Radiology API

Coming soon

Why Separate APIs?

Although the APIs share the same technical architecture, data structure, and validation framework, they are exposed as separate endpoints because they serve distinct ABM products and business workflows. This separation allows each product to apply its own determination logic, policy rules, pricing methodologies, and operational processes while maintaining a consistent integration experience for health plans.