User Guide

The Optum Real Claim Inquiry API simplifies how your practice accesses claim information by providing real-time visibility into both summary and detailed claim statuses. It allows health care providers to quickly retrieve claim data, check the current status and take informed next steps—such as submitting a reconciliation or appeal—at both the claim and individual service line levels.

When to use it:

• Check the status of claims at both the summary and line levels
• View adjudication codes and any existing appeal or reconciliation requests
• Decide on appropriate next steps, including appeals or reconciliation

How it helps:

• Retrieves claim information using flexible search options like claim ID, patient account number, member details with date of service or provider TIN within a date range
• Searches for reconciliation, pend or appeal tickets using a ticket number or date range
• Confirms claim receipt through acknowledgment status
• Identifies available actions at the service line level
• Downloads documents related to specific claims for reference or follow-up

What you’ll see:

• Available next-step actions at the service line level
• Summary and detailed claim information
• Real-time status of appeal, pending or reconciliation tickets

How it’s different:

• Real-time access to claim status, reducing delays and uncertainty
• Immediate visibility into actions at the service line level
• Direct document downloads for streamlined follow-up
• Interoperability across payers, minimizing manual workarounds
• Improves transparency with adjudication codes and appeal history