Optum Eligibility API is one of 166 APIs that Optum publishes on the APIs.io network, described by a machine-readable OpenAPI specification.
Tagged areas include Eligibility. The published artifact set on APIs.io includes an OpenAPI specification, an API reference, a getting-started guide, authentication docs, a changelog, and API documentation.
This API exposes
4 operations
across 4 paths,
and defines 93 schemas.
It is described by OpenAPI 3.2.0, at version 1.0.
Requests are made against 2 base URLs: https://sandbox-apigw.optum.com, https://sandbox-apigw.optum.com/oihub.
4 operations4 paths93 schemas4 POST
Metadata
The identity and technical contract details declared by the specification.
Specification
OpenAPI 3.2.0
API Version
1.0
Base URL
https://apigw.optum.com/medicalnetwork/
Authentication
HTTP Bearer, OAuth 2.0, HTTP Bearer
Resource Areas
1
Authentication & Security 3
Optum Eligibility API declares
3 security schemes
for authenticating requests.
It accepts HTTP bearer tokens (JWT) (bearer-key).
It supports OAuth 2.0 (oAuth) using the clientCredentials flow, exposing 5 scopes.
It accepts HTTP bearer tokens (JWT) (bearerAuth).
oAuth — This API uses OAuth 2 with the clientcredentials grant flow.
bearerAuth — Enter a Bearer access token. The API Explorer applies the Bearer scheme.
Paths & Operations 4
Across 4 paths, the API surfaces 4 operations — 4 POST. Each is listed below with its method, path, parameters, and response codes.
Eligibility 4
Medical Eligibility
POST
/medicalnetwork/eligibility/v3/
Check Eligibility
medicalEligibility2 paramsbody→ 200
POST
/medicalnetwork/eligibility/v3/raw-x12
Check Eligibility x12
rawX122 paramsbody→ 200
POST
/eligibility/v1/pre-service/member
Call checkEligibility query
checkEligibility3 paramsbody→ 200400401500
POST
/oihub/dental/eligibility/preservice/v1
Pre-Care Eligibility Check
checkEligibility2 paramsbody→ 200400401403500
Schemas 93
The contract defines 93 schemas that model the data the API accepts and returns. The most detailed are PlanInformation (42 properties), BenefitsAdditionalInformation (38 properties), BenefitsDateInformation (34 properties), ResponseMember (34 properties). Each schema is shown below with its type and property counts.
RequestSubscriber
object
Loop: 2100C, Notes: Subscriber Detail
28 properties
HealthCareDiagnosisCode
object
HealthCareDiagnosisCode
2 properties
PlanDateInformation
object
PlanDateInformation
32 properties
AdditionalIdentification
object
Loop: 2100C and 2100D, Segment: REF Notes: Additional Identification
11 properties
ResponseProvider
object
Provider
19 properties
Address
object
Address: N3 and N4
8 properties
SubscriberTraceNumber
object
SubscriberTraceNumber
5 properties
ContactInformation
object
ContactInformation
2 properties
MedicalEligibility
object
MedicalEligibility
11 properties2 required
RawX12Request
object
1 property
Response
object
18 properties
Error
object
6 properties
Provider
object
Loop: 2100B, Segment: NM1, Notes: Information Receiver
14 properties
Payer
object
Payer
16 properties
PlanInformation
object
PlanInformation
42 properties
BenefitsRelatedEntity
object
BenefitsRelatedEntity
12 properties
DtpDate
object
DtpDate
3 properties
PlanStatus
object
PlanStatus - Deprecated please use benefitsInformation
5 properties
MedicalProcedure
object
Loop: 2110C and 2110D, Notes: Eligibility or Benefit Information, EQ02 and beyond only
4 properties
RequestDependent
object
Loop: 2000D, Notes: Dependent Detail
26 properties
CompositeMedicalProcedureIdentifier
object
CompositeMedicalProcedureIdentifier
6 properties
AdditionalInformation
object
AdditionalInformation
1 property
Encounter
object
Loop: 2110C and 2110D, Notes: Eligibility or Benefit Information
12 properties
BenefitsServiceDelivery
object
BenefitsServiceDelivery
16 properties
EligibilityAdditionalInformation
object
EligibilityAdditionalInformation
4 properties
ProviderInformation
object
ProviderInformation
2 properties
BenefitsDateInformation
object
BenefitsDateInformation
34 properties
BenefitsInformation
object
BenefitsInformation
30 properties
BenefitsAdditionalInformation
object
BenefitsAdditionalInformation
38 properties
InformationReceiverName
object
Loop: 2100B, Notes: Information Receiver Name
15 properties
ResponseMember
object
ResponseMember
34 properties
HealthCareInformation
object
Loop: 2100C and 2100D, Segment: HI, Element: HI01-1 HI01-2, Notes: Health Care Diagnosis
2 properties
MetaData
object
Meta data about the response
6 properties
Contacts
object
Contacts
2 properties
AssociatedIds
object
Collection of different identifiers associated with the member
12 properties
ContactDetails
object
3 properties
SubMessage
object
Sub-message details
11 properties
PatientLiability
object
Patient liability details
6 properties
Address_2
object
Address details
8 properties
LimitationInfo
object
5 properties
EligibilityBasic
object
Basic eligibility information
7 properties
CobMember
object
COB member summary
2 properties
PlanDetail
object
Cost sharing details for a specific network status
4 properties
CobDetail
object
COB member summary
4 properties
EligibilityPreCheckRequest
object
Request object for Eligibility Pre-Check operation
2 properties
EligibilityPreCheckResponseWrapper
object
Wrapper for Eligibility Pre-Check Response
1 property
ContactInfo
object
1 property
PrimaryCarePhysician
object
Information about the member's primary care physician
14 properties
ProviderNetwork
object
Information about the member's network status
3 properties
Payer_2
object
COB Payer Information
3 properties
CoPayDetails
object
Detailed message information
7 properties
EligibilityResponse
object
Response containing eligibility details
1 property
ExactCopay
object
Exact copay information
2 properties
MessageDetail
object
Detailed message information
7 properties
MedicaidEntitlement
object
Medicaid entitlement information
3 properties
Variables
object
Variables for the Eligibility Pre-Check operation
1 property
CoPayListItem
object
Co-pay list item details
6 properties
ServiceDetails
object
Information about a specific covered service
8 properties
CopayDetail
object
Copay detail information
2 properties
Input
object
Input data for the Eligibility Pre-Check operation
22 properties2 required
CoordinationOfBenefits
object
Details about coordination of benefits
3 properties
CobPrimacy
object
COB primacy information
3 properties
COBUpdateInformation
object
COB update information
2 properties
CoInsuranceListItem
object
Co-insurance list item details
6 properties
ServiceDetail
object
Detailed service level information
2 properties
AdditionalInfo
object
Additional plan related information
23 properties
TransferOfPropertyPenaltyPeriod
object
Transfer of property penalty period details
2 properties
SubMessageCopay
object
Sub-message details
13 properties
InsuranceInfo
object
Insurance information
19 properties
Eligibility
object
Eligibility details containing various attributes
8 properties
MemberInfo
object
Member Information
11 properties
IdCard
object
Information about the member's ID card
3 properties
WaiverLiability
object
Waiver liability details
6 properties
RelationShipInfo
object
Relationship Information
2 properties
PlanLevel
object
Deductible information
3 properties
COBPolicy
object
COB policy information
9 properties
DelegatedInfo
object
Delegated Information
4 properties
ServiceLevel
object
Detailed service level information
2 properties
Messages
object
Messages related to a service
7 properties
EligibilityInput
object
11 properties11 required
Contact
object
1 property
AssociatedIds_2
object
4 properties
PlanLevel_2
object
3 properties
EligibilityRecord
object
1 property
GraphQLRequest
object
2 properties2 required
DelegatedInfo_2
object
3 properties
Member
object
11 properties
Address_3
object
8 properties
PlanAmount
object
3 properties
EligibilityResponse_2
object
1 property
CodeDescription
object
2 properties
InsuranceInfo_2
object
18 properties
EligibilityInfo
object
7 properties
Specification
The full machine-readable OpenAPI contract behind this narrative.
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