Overview

The Real Claim Inquiry API is designed to streamline access to real-time claim status updates, empowering healthcare providers with timely, actionable insights across the claim lifecycle. This API enables users to retrieve both summary and detailed claim information, check the claim status, and make informed decisions regarding reconsiderations or appeal requests at both the claim and line levels.

Key Capabilities

• Search claim
  - Retrieves both summary and detailed claim information using parameters such as claim ID,
  patient account number, member details with date of service (DoS), or provider TIN with a DoS range.
• Search claim ticket
  -Enables search for RECON, PEND, or APPEAL tickets using a ticket number or a date range
  (maximum 30 days), supporting efficient tracking of claim resolution processes and allowing access
  to view the list of attachments associated with ticket.
• Search 277CA
  -Provides access to claim acknowledgment data, helping confirm receipt and processing status
  of submitted claims.
• Get claim line action
  -Returns available actions at the service line level, enabling providers to take informed next steps
  such as initiating reconsiderations or appeals.
• Get document
  -Allows download of documents related to a claim, supporting documentation needs for audits,
  appeals, or internal reviews.

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 the
   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 on the Try It page.

Sandbox Use for Live and Mock Data Testing

1. Customers must have purchased an API with status “subscribed” in their AI Marketplace account, please work with 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 of - the Real Claim Enquiry 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.