API Data Dictionary

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

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.

Overview

The Real Claim Actions API streamlines workflows by consolidating interactions with multiple backend APIs, enabling providers to verify the accuracy of claims during the submission process.

The Real Claim Actions API streamlines and improves the efficiency of submitting claims, reconciliation requests, appeals, and supporting documentation at the point of billing.
By consolidating interactions with multiple backend APIs, it enables providers to verify claim accuracy during the submission process and receive real-time feedback to minimize errors.

Claim Actions allows users to validate key components such as member eligibility, coordination of benefits, prior authorization determination, and claim edits as part of the precheck process—prior to claim adjudication. It provides real-time feedback to ensure claim accuracy. The API accepts claims in X12 format and returns responses in X12 277CA and 999 formats.

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

Key Capabilities

• Validates claims pre-submission
  -Validates claim meets X12 standards
  -Confirms eligibility and coordinates benefits
  -Validates benefits and prior authorization
  -Identify billing errors
• Submits claims and requests
  -Facilitates claim submission
  -Facilitates submission of reconciliation requests and appeals
  -Facilitates resubmission of existing reconciliation requests
• Attaches supporting documents
  -Facilitates submission of supporting documentation — whether solicited

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 Try It page to request complete API response or customize response for
   Sandbox API endpoint only.

OR
-Use Postman to request complete API response or customize response for 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 the AI Marketplace account, please work with 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. The customer 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 in the TRY IT page.

API Endpoint

Notes:
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 our APIs.

To perform load testing and production data testing, we recommend using our APIs in the production environment.

API health check

The health check endpoint checks the operating status of our 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 an Optum Real API - the Real Pre Service Eligibility API, go to
  Healthcheck If the API engine is working correctly and if the entry points are accessible, the API operating status response shows "OK."

NOTE If you receive a response other than 200 OK, the health check failed.
Please submit a service ticket with Optum.