User Guide

The Optum® Real Patient Benefit Check API helps providers validate patient benefits as well as prior authorization and referral requirements before care is delivered. This helps streamline workflows and reduce delays in patient care.

When to use it:

• When scheduling a patient appointment
• After an appointment is scheduled
• Before submitting a prior authorization request
• When you’re unsure if a referral is needed

How it helps:

• Identifies prior authorization requirements
• Identifies referral requirements
• Verifies coverage requirements based on the patient’s insurance
• Reduces the risk of claim denials by proactively addressing prior authorization needs
• Reduces surprise bills and improves patient satisfaction

What you’ll see:

• Clear messaging about whether prior authorization is required
• Clear messaging about whether referral is required
• Language designed for quick interpretation by office staff

How it’s different:

• Confirms if the patient’s policy covers the procedure
• Flags if a visit limit applies
• Validates benefits at the CPT level