Prior Authorization V1 Getting Started

Overview

The Prior Authorization Inquiry API allows providers to check authorization statuses directly from payers in real-time by connecting EDI, web portal payers, and UM vendors for efficient authorization inquiries. This API is designed to streamline the process of obtaining prior authorizations, which can often be a cumbersome and time-consuming task. By integrating with various payers and vendors, it ensures access to the most up-to-date information regarding authorization statuses, allowing for quicker decision-making and improved patient care.

The service accepts prior authorization inquiry requests in the form of EDI-X12 278x215 payloads and returns EDI-X12 278x217 payer response to the consumer.

Additionally, the Prior Authorization Inquiry API supports high levels of customization, providing for adaptability of requests and responses to meet specific requirements. This flexibility can help providers manage workflows more effectively and reduce administrative burdens, leading to enhanced operational efficiency.

Key Features

• Real-time authorization status checks
• Support for multiple payer connections
• Integration with EDI and web portal payers
• Compatibility with UM vendors
• Accepts JSON inquiry requests and return JSON responses
• Provides a simple JSON validation
• Translates the JSON request to X12 for downstream processing
• Translates the X12 response back to JSON to return to the consumer

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NOTE

The JSON attributes in our APIs use snake-case, with the first letter of the attribute in lower case as in umClearingHouseId, tradingPartnerServiceId (the Payer ID; this will vary based on the payer you want to connect to) Our APIs are case-sensitive and your JSON request body must observe this convention.

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NOTE

For sandbox usage, all fields must have the correct predefined values to obtain a successful response. Inventing new PMI values or using real-world PMI values will result in errors. Please provide all of the values, such as umClearingHouseId, payerId, and so on marked as required (R) in your API requests.

• Sandbox environment endpoint

https://sandbox-apigw.optum.com/medicalnetwork/eligibility/v3

• Production environment endpoint

https://apigw.optum.com/medicalnetwork/eligibility/v3

Available endpoints

• 278x215 /inquiry/x12
• JSON /inquiry
• 278x217 /submission/x12
• JSON /submission
• /healthcheck - Verifies that the operating status of the requested API is optimal.
• /apip/auth/v2/token - Generates an authentication token using your client_id and client_secret.

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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.