Overview

The Real Pre-Service Eligibility API is designed to provide a flexible, streamlined solution that aligns with provider workflows at key moments such as appointment scheduling and check-in. The API uses JavaScript Object Notation (JSON) and GraphQL for requests and responses. All API traffic is encrypted over HTTPS and authentication is handled with OAuth2.

This API simplifies provider interactions by consolidating multiple API capabilities into a single, easy-to-use interface, which reduces complexities. It supports efficient integration by delivering relevant data tailored to the provider’s intent and workflow.

Key functions include authenticating and authorizing incoming requests, performing initial validations (e.g., rate limits and thresholds), and assigning unique identifiers for end-to-end traceability. Requests submitted using GraphQL queries are intelligently routed to the appropriate backend services, and providers receive consolidated, actionable responses that support faster decision-making and reduce administrative burden.

Built on GraphQL, the API enables precise data retrieval, minimizing unnecessary data transfer and improving performance. An integrated analytics and traceability layer captures the full request lifecycle, enabling robust monitoring, reporting, and continuous improvement.

Key Capabilities

• Subscriber and dependent demographics information
  - Captures essential member details such as name, date of birth, relationship status and dubscriber ID
  for accurate identification.
• Primary care provider (PCP) information
  - Provides information about the member’s assigned PCP, including name, contact details, and
  specialty supporting referrals and billing.
• Insurance and plan information
  -Delivers insights into plan type, coverage details, and policy effective dates to ensure
  accurate insurance verification.
• Coverage-level and service-level financials
  - Includes copay, deductible, coinsurance, additional coinsurance, and other financial data relevant
  to service-level eligibility.
• Delegation information
  -Identifies third-party administrators or delegated entities managing specific aspects
  of the member’s plan.
• Coordination of benefits
  -Details any additional health coverage the member may have, helping determine
  payment responsibilities.
• Member ID card access
  -Provides digital access to the member’s ID card for use in service authorization and billing.
• Network status and tiering
  -Indicates provider participation status and tiering, which may impact coverage and out-of-pocket costs.

The Real Pre-Service Eligibility API provides pre-service member eligibility information via a GraphQL endpoint.

API Data Dictionary

The attached spreadsheet serves as a comprehensive data dictionary for the API. It includes detailed documentation of the following components:

📘

NOTE: If you need a copy of the "Data Dictionary" please reach out to support.

Request elements-Describes the input parameters required for the API or data query.
Includes field names, data types, required/optional status, and descriptions.

Response elements-Lists the fields returned in the response payload.
Includes field names, data types, possible values, and descriptions.

Query samples-Provides graphql example queries for each operation to demonstrate how to interact with the API.
Useful for developers and testers to understand expected formats and usage patterns.

Error codes-Documents the possible error codes returned.Includes code values, error messages, and explanations to aid in troubleshooting.

Test API

1. Use token generated using client ID and secret key for sandbox or production.
2. Download API specs from overview page - Every API overview section provides links to download the file in a JSON format, which generates our documentation for developers to use.
3. Hit API endpoint through the following options:
   -Use the Try It page to request a complete API response or customize response for
   Sandbox API endpoint only.

OR
-Use Postman to request a complete API response or customize response for the sandbox and
production API endpoints.

NOTE: Do not submit PHI or PII data in the Try It page.

Sandbox Use for Live and Mock Data Testing

1. Customers must have purchased an API with status “subscribed” in the AI Marketplace account. Please work with your API consultant to associate provider TIN(s) before sending live data to the sandbox environment.
2. Customers must use their sandbox credentials to send live data to the sandbox environment for the API purchased.
   At this point, responses will be based on the live data submitted to the sandbox environment as opposed to mock data preloaded to the sandbox environment.
3. Customers will retain the ability to query mock responses from a sandbox environment by using an optional request header called “environment”. By placing the value “sandbox" in the optional header, the request returns mock responses.
   NOTE: Do not submit PHI or PII data on the Try it page.

API Endpoint

NOTE:
DO NOT perform load testing or production data testing in the sandbox environment. Please use the sandbox ONLY to view sample API responses to HTTP requests using our predefined values and to familiarize yourself with the APIs.

To perform load testing and production data testing, we recommend using the APIs in the production environment.

API Health Check

The health check endpoint tests the operating status of the API. It is a ping for the API entry point to ensure it is accessible. This is the first thing you can do if something goes wrong.

• To run the health check the Real Pre-Service Eligibility API, visit the
  Healthcheck page. If the API engine is working correctly and the entry points are accessible, the API operating status response will show " 200 OK."

NOTE If you receive a response other than 200 OK, the health check failed.
Please submit a service ticket with Optum for support.