Overview

The Real Claim Pre-Check API  is designed to streamline the submission and processing of claims, offering providers a unified and efficient integration experience. By consolidating multiple backend API interactions into a single interface, this API simplifies workflows and enhances accuracy throughout the claim lifecycle.

This API enables real-time submission and validation of key claim components—including member eligibility, coordination of benefits, prior authorization requirements, and claim edits—helping providers improve claim accurracy before adjudication. It accepts claims in X12 837 format and returns responses in X12 277CA and 999 formats.

Built to support HIPAA-compliant validation, the API orchestrates a series of checks that help reduce the risk of claim rejections, improve processing efficiency, and enhance transparency for both providers and members.

Key Capabilities

• X12 validation
  -Performs Online Transaction Validation and Management (OTVM) in real time to validate
  X12 837 claims.
• Member eligibility verification
  -Confirms active membership for the date of service to ensure eligibility.
• Coordination of benefits
  -Validates whether the member has additional health coverage and determines
  payment responsibilities.
• Benefits and prior authorization requirements
  -Validates that benefits and prior authorization requirements are met.
• Claim edits and validation
  -Conducts pre-submission edits to catch errors and ensure compliance with payer-specific rules.
• Real-time feedback
  -Provides actionable responses to support accurate member responsibility and
  provider payment estimates during checkout.

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 complete API response or customize response for the
   sandbox API endpoint only.

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

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 their AI Marketplace account, please work with your API consultant to associate provider TIN(s) before sending live data to 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 requests return 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 the entry points are accessible. This is the first thing you can do if something goes wrong.

• To run the health check of the Real Pre Service Eligibility API, visit the
  Healthcheck page. If the API engine is working correctly and if 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.