Overview

The Real Patient Benefit Check API offers a comprehensive and flexible solution to verify member benefit coverage, limitations, accumulators, and authorization requirements. Designed for seamless integration into user interfaces, it supports real-time decision-making for healthcare services by delivering accurate and actionable benefit information.

By leveraging this API, users can quickly assess benefit eligibility and limitations for specific services, determine whether prior authorization or referral is required or already available in the file, and access clear, member-specific benefit language that includes in-network and out-of-network cost share details, limits, and exceptions. This functionality helps enhance operational efficiency, reduce administrative burden, and improve the member experience by enabling smarter, faster, and more informed healthcare service decisions.

Key Capabilities

• Prior Authorization inquiry- Indicates whether a prior authorization is needed for a specific service, ensuring compliance with payer requirements before service delivery.
• Prior Authorization in file- Checks if a referral or prior authorization is already on file for the member, reducing redundant submissions and streamlining care coordination.
• (coming soon)Referral inquiry_ Determines whether a referral is required for the member to receive the intended service, helping avoid unnecessary delays or denials.
• (coming soon)Benefit language -Provides detailed cost share information for both in-network and out-of-network services, including limits and exceptions, supporting transparency and informed decision-making.
• (coming soon)Benefits at CPT Code _ Returns benefit details and limitations based on the specific CPT code, helping providers understand coverage for particular procedures or services.

API Data Dictionary

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

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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 th sandbox and
production API endpointa.

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 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 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 checks tests the operating status of our the API. It is a ping for the API entry point to ensure the entry points areit is accessible. This is the first thing you can do if something goes wrong.

• To run the health check of an Optum Real API - the Real Pre Service Eligibility API, go to
  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.