Eligibility V3 Getting Started

Overview

Every medical provider and medical institution uses some type of systemic query to determine if a medical patient has medical insurance. The Eligibility API is an easy way to check if a patient has healthcare coverage with a specific insurance company (payer). Knowing if a patient has medical insurance, enables the medical provider or institution to make informed decisions on how to handle the patient's needs. For example, when an appointment is scheduled with a doctor, patient's insurance card is needed, which will be used to run an eligibility request to the insurance company to verify that the insurance is valid. The response of that eligibility request will also provide the co-pay amount.

Optum's Eligibility requests help providers verify details on many different types of information:

• Types of procedures covered by an insurance policy
• Extent or percentage up to which, the insurance covers the medical procedures under a policy
• Amount for which, patients will be financially responsible
• Patient responsibility details, such as co-payments, coinsurance, and deductibles
• More about many other plan membership features

Our Eligibility API solution provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement. Providers get better front-end information to improve claiming processes and reimbursement rates. For payers, claims spend less time in pending status, and fewer rejected and reworked claims.

Upon an HTTP request, the Eligibility API translates the standard X12 EDI 270 Eligibility transaction to more readable Javascript Object Notation (JSON) format, so it is more accessible to developers and easily integrated into users’ applications. The X12 standards are managed in the background, and give you efficient access to medical subscriber or dependent information about their plan membership, copays, coinsurances, deductibles, and more in an easy-to-use, human-readable format.

We also support a dedicated X12-formatted Eligibility API to send your submission in X12 EDI format. It supports the standard syntax for a complete X12 EDI 270 transaction set.

Eligibility API functionality

• Enables you to quickly look up a patient’s insurance benefits.
• Check co-insurance, co-pays, deductibles, and expected out-of-pocket amounts along with other insurance benefits for a subscriber or dependents of the subscriber on a policy.
• Allows you to request eligibility for service types.
• Optionally, the serviceTypeCode parameter allows you to specify particular service(s) in a request.
  If you do not specify a service type, the API makes the request for general benefit coverage information (this is also enabled by specifying the default serviceTypeCode 30).

The eligibility and benefit responses vary depending on the trading partner and health plan in which a member is enrolled. Our API returns all information received from the trading partner in the Eligibility response.

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NOTE

• If you only plan to use a few daily transactions, you can use npd or cap for your Medical Network transaction needs.
  It provides most of the features supported by an API console but only allows manual entry for all data needed for a transaction. It contains Payer Lists, the Payer List Enrollments wizard, and other API customer resources.
• For providers sending hundreds of daily requests, we recommend using our APIs to be able to automate the submission processes and have a better fit for your business needs.

Related Topics

• API Reference
• Security and Authorization V2
• API URLs and Endpoints
• API FAQs
• Error Messages
• Troubleshoot APIs with Metadata