Use the Professional Claims V3 API
The Professional Claims APIs are designed for medical providers to submit insurance claims to payers.
Before submit your claims to the payer, use our Professional Claims /validation endpoint to check and validate your upcoming claim submission. Our /validation endpoint will not send your transaction to the payer. The validation does not examine the actual contents of your claim; it checks for the correct well-formed syntax of the submission and elements, such as correctly summing service line charges and verifying codes.
NOTE
For more sophisticated checking of Professional claims, consider contracting for our Professional Claims Integrated Rules API, which applies intelligent rules evaluation to the actual contents of your claim, with rules tailored to the specific needs of your practice.
Many claims get rejected by either the clearinghouses, which forward medicals claims to the payer networks, or by the payers themselves, because of needless mistakes in formatting or syntax.
NOTE
The JSON attributes in our APIs use snake-case, with the first letter of the attribute in lower case as in
claimInformation. Our APIs are case-sensitive and your JSON request body must observe this convention.
Professional Claims endpoints and URLs
| Task | Endpoint | Description |
|---|---|---|
| Request Method | POST | |
| Bearer Token | /apip/auth/v2/token | |
| API endpoint | /professionalclaims/v3 | |
| Validation endpoint | /professionalclaims/v3/validation | |
| Healthcheck endpoint | /professionalclaims/v3/healthcheck | Verifies that the operating status of our APIs is optimal and if the APIs are running and are accessible. For more information, see API Healthcheck. |
| Raw-X12 | /professionalclaims/v3/raw-x12-validation/professionalclaims/v3/raw-x12-submission | |
| Operation Mode | Real-time, one request | |
| Consumes | Application/json | |
| Produces | Application/json | |
| Sandbox URL | https://sandbox-apigw.optum.com/medicalnetwork/professionalclaims/v3 | |
| Production URL | https://apigw.optum.com/medicalnetwork/professionalclaims/v3 |
Professional claims elements
The Professional Claims API contains a series of JSON objects that use various important elements for completing submission of claims, including but not limited to the following:
| Element | Description |
|---|---|
claimReference | Contains important values, such as the payerId, customerClaimNumber, claimType, and other values that mostly will be managed programmatically. |
submitter | Provider identification, including information, such as the organizationName. |
subscriber | Includes the patient's insurance member ID and policyNumber. |
dependent | If necessary, information about the insurance policy holder's dependent who received the medical services. |
providers | Providers involved with the medical claim. |
claimInformation | A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information. This section contains the standard charge entries that the provider(s) expect to receive for their services. |
Using the Healthcheck endpoint
The /healthcheck endpoint verifies that the operating status of our APIs is optimal and the APIs are running and are accessible. Please see example in API Health Check.
Using the Validation endpoint
The /professionalclaims/v3/validation endpoint checks for the correct values of the claimReference object, which confirms that you will be sending the claim to the right place and it will not be rejected by the clearinghouse. Please see example in Use the Validation Endpoint.
✍️ In the Professional and Institutional Claims sandbox request, using value: test00005 (lower case and not uppercase), for
fieldName: patientControlNumber returns EDITS canned response.
Updated about 1 month ago