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Every API section in this developer portal includes its own frequently asked questions (FAQs) section, which includes tips and solutions to some of the most common questions asked by customers, developer community, and internal staff about the use of our APIs.

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Scroll down to the end of this section for links to all our APIs FAQs.

What kind of resources do you offer in your API documentation?

Please see Readme.

Is there a call to understand if a provider is PAR or EPO for a given insurance provider?

We do not have an API to check provider directories to see if they are a part of a network.

What API domain should be used?

Please see API Request Header.

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BEARER TOKEN LIFESPAN

The lifespan of a Bearer token is one hour (3600 seconds) for both sandbox and production environments.

We recommend automating transactions to use the tokens generated over the token lifespan. Obtaining tokens for each transaction is less efficient and does not improve the security criteria for any transactions.

How can I check the operating status of the APIs?

Please see API Health Check.

What is the difference between an Institutional Claims and a Professional Claims?

  • Professional billing typically uses the 837p transaction (or the CMS-1500 hard-copy form)
  • Institutional billings use the 837i transaction

We support both types of electronic claims and transactions. Institutional Claims and billing sometimes also encompasses collections while, Professional Claims and billing do not.

Professional billing controls the billing of claims generated for work performed by physicians, suppliers, and other non-institutional providers for both outpatient and inpatient services.
One commonality: our APIs help support and automate insurance coding for both Institutional Claims and Professional Claims.

Do you support appeals for denials? Are there any APIs through which these appeals can be submitted?

Please see Resubmit a Denied Claim.

How do we re-submit a claim that was denied – Appeal & Denial

Please see Resubmit a Denied Claim.

When a claim is submitted via the API, the API returns a claim ID. What API can I use to fetch the payer's claim number before we receive the ERA, ideally the next day after the claim is submitted successfully?

The payer-assigned claim ID will be returned through the SF and SD reports that we provide through the responses and reports API. Additionally, you may be able to check the provider portal for the payer for this information.

File Formats supported

Please see Batch File Formats Supported.

File types

Please see File Types Supported.

What is the difference between the Integrated Rules API and the regular Institutional Claims API?

The standard Institutional Claims API uses a separate set of rules and logic for scrubbing an Institutional Claims, and is automatically applicable across a range of institutional specialties. The Integrated Rules Institutional API provides greater specialization through the selection of Knowledge Packs to support your provider's medical specialties. It can be considered complementary to the standard Institutional Claims API.

Where can I get the Consolidated 270/271 Implementation Guide?

You need to license it directly from the X12 org.

Is there a webhook that tells us when there is a change in status of a claim? We could have thousands of outstanding claims at a time, and rather than regularly checking a claim's status with an API call, it might be beneficial for us if we could get notified when there is an update.

We do not offer webhooks for this information. You should pull the payer report information we send through the responses and reports API. Here is a list of available reports.

What is Y, N, U, and W?

Please InNetworkIndicator values in Glossary.

As a partner with what is the process after providers complete EDI enrollment? Who updates enrollment status for the provider?

Please see Process after completing Providers' EDI Enrollment.

Is there a way to retrieve the cost estimate data for multiple providers from a single API call?

No, the purpose is to provide the patient an out-of-pocket estimate for a specific procedure/service type code. Not for multiple providers.

What is a StatusTypeCode?

Please see StatusCodeType and Use ServiceType Codes.

What is the difference between the Payer List, Revenue Performance Advisor Payer List, ConnectCenter Payer List, Attachment Payer List?

Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.

What is the Claim submission flow?

Please see claim submission workflow for instructions.

What to do if DNS error occurs while calling the API?

Please see DNS Error for more information.

When doing a payer search (accessed via Connect Center > Payer Tools > Payer Search) and selecting for Claims and Eligibility products, I get 3 different IDs. These are CPID, Real Time ID, and Payer ID. Why are they not particularly unique?

Please see ConnectCenter FAQs.

Is submitter ID provided by you? Will this be provided for each of our clients?

At the time of account creation, only one submitter ID is assigned to your organization. We can set up your organization as a "master billing organization", which allows for you all to have individual submitters under the organization's umbrella. here is a document that explains this in further detail. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If you would like to pursue individual submitter IDs, please reach out to our team at [email protected] to schedule a call for additional information.

How to handle multiple authorization numbers per claim?

If the Institutional Claims required multiple authorization numbers, multiple claims need to be submitted. Submission through the Professional API allows for prior authorization information to be submitted at both the claim and line level Institutional Claims APIs allows for prior authorization information to be submitted at the claim level only. Here are Handle Multiple Authorization Numbers per Claim examples from our Open API Specs.

Does this information mean the following: If the service is classified as "Hospital", the deductible that should be paid by the patient is $100 during the entire calendar year?

Yes, this would be read as the deductible that should be paid by the patient is $100 during the entire calendar year for in-network services.

What does the type "Limitations" mean, and what does this example say? Does it imply that the payer will not pay the patient more than $2000 for Orthodontics?

This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.

Concerning "Out of Pocket" – do we receive per-service Out of Pocket (Stop Loss) and the remaining Deductible, and then should we calculate if the patient should pay anything or not? How does it work?

Please see "out-of-pocket" definition in Glossary.

How can the "Benefit Description" type be used?

Please see "Benefit Description" in Glossary.

What does inPlanNetworkIndicator mean?

Please see InPlanNetworkIndicator definition in Glossary.

Do all services have Out of Pocket (Stop Loss), or is it only applicable to some of them? And does it differ for services under one and the same insurance plan?

This is service and payer specific. This depends on the individual plan of the member and should be addressed with the payer directly. Please see out-of-pocket definition in Glossary.

How can the changing tradingPartnerServiceId be used in production?

The tradingPartnerServiceId is an ID used by the clearinghouse for the payer you are attempting to reach for eligibility. A list of sandbox payers can be found here. The production list can be accessed through the ConnectCenter once contracting is complete.

For example, there are a lot of possible tradingPartnerServiceIds that could be used to retrieve data for Joeone. Is this just for simulation, or do we need to make only one request to get the entire data about Joeone in the production environment?

Please review the documentation on eligibility in our developer portal.

What does the controlNumber mean?

Please review the documentation on eligibility and glossary in our developer portal.

If we are a Provider, and we are setting our first-ever Service Catalogue, where we are using common human language, like "Consultation of a Pediatrician", "Consultation of a Neurologist", or "Consultation of an Endocrinologist", etc. And in our Service Catalogue, the unique line items are named exactly like this. What would you recommend using as the Baseline for Coding these items described in common human language? Would CPT code be more logical or ICD-10s or STC Codes? And could you please provide an example where we can find that mapping?

The mapping of these codes would be specific to each payer. The 270 currently supports STC codes dated up to 2009. The specific categorizes in which the CPT/ICD10 codes would fall under would need to be confirmed with the payer directly.

Does the X12 list format contain only groups of covered services or individual services as well?

Here is the list of covered services and is dated prior to 2009.

What is the recommended practice for mapping X12 to CPT and/or ICD-10 codes, and how is it typically executed?

This should be done with the payer depending on the specific service you are rendering. Each payer can potentially classify individual CPT/ICD 10 codes under different STC codes.

Is there any information available about the total annual limit of the health plan and how much of it remains for a specific subscriber?

Yes, it is the out-of-pocket (Stop Loss) and this represents the maximum amount of the patient's portion of responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The out-of-pocket (Stop Loss) amount typically represents the combined total mount of deductible and co-insurance payments made by the patient. Some health plans have out-of-pocket (Stop Loss) amount for the individual patient and a higher amount for the entire family.

Describe the precise meanings of "timeQualifier" and "timeQualifierCode", and help me identify all possible values for that variable?

Please see Allowed Time Qualifier Reference for a list of allowed values.

What is the definition of "benefitAmount", and does it vary for different services for the same subscriber? What does it signify when it is '0'?

Please see Benefit Amount in Glossary.

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Updated 26 days ago