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Optum

Optum Professional Claims API

Professional Claims

Documentation Provider Profile APIs.io OpenAPI GitHub

Optum Professional Claims API is one of 166 APIs that Optum publishes on the APIs.io network, described by a machine-readable OpenAPI specification.

Tagged areas include Professional Claims. 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 68 schemas. It is described by OpenAPI 3.2.0, at version V3.

Requests are made against a single base URL, https://sandbox-apigw.optum.com.

4 operations 4 paths 68 schemas 4 POST

Metadata

The identity and technical contract details declared by the specification.

Specification
OpenAPI 3.2.0
API Version
V3
Base URL
https://apigw.optum.com/medicalnetwork/
Authentication
HTTP Bearer
Resource Areas
1

Authentication & Security 1

Optum Professional Claims API declares 1 security scheme for authenticating requests. It accepts HTTP bearer tokens (JWT) (bearer-key).

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.

Professional Claims 4

Professional Claims

POST
/medicalnetwork/professionalclaims/v3/validation
Claim Validation
validateClaim 2 params body → 200
POST
/medicalnetwork/professionalclaims/v3/submission
Claim Submission
processClaim 2 params body → 200
POST
/medicalnetwork/professionalclaims/v3/raw-x12-submission
Claim Submission x12
rawX12Submission 7 params body → 200
POST
/medicalnetwork/professionalclaims/v3/raw-x12-validation
Claim Validation x12
rawX12Validation 7 params body → 200

Schemas 68

The contract defines 68 schemas that model the data the API accepts and returns. The most detailed are ClaimInformation (41 properties), ServiceLine (38 properties), ServiceLineOrderingProvider (22 properties), ServiceLineProvider (22 properties). Each schema is shown below with its type and property counts.

ServiceLine
object
Loop 2400
38 properties 2 required
ServiceFacilityLocation
object
7 properties 2 required
ProfessionalService
object
13 properties 6 required
ContractInformation
object
CN1
6 properties 1 required
ClaimDateInformation
object
DTP
18 properties
LineAdjudicationInformation
object
SVD, CAS, DTP and AMT
11 properties 6 required
ClaimPricingRepricingInformation
object
HCP
10 properties 2 required
ClaimInformation
object
Loop2300
41 properties 11 required
ConditionInformation
object
HI
1 property 1 required
Address
object
N3 and N4
7 properties 2 required
ServiceLineOrderingProvider
object
22 properties 1 required
Measurements
object
3 properties 3 required
MedicareOutpatientAdjudication
object
Loop: 2320, Segment: MOA
5 properties
ContactInformation
object
PER
5 properties 1 required
AmbulanceCertification
object
CRC
2 properties 2 required
ServiceLineReferenceInformation
object
8 properties
RawX12Request
object
1 property
OtherPayerSupervisingProvider
object
Loop 2330F
1 property 1 required
Submitter
object
Loop: 1000A
5 properties 1 required
Response
object
11 properties
Error
object
6 properties
ClaimSubmissionRequest
object
18 properties 6 required
SupportingDocumentation
object
Loop: 2440, Segment: FRM
5 properties 1 required
Subscriber
object
Loop: 2000B
16 properties 1 required
EpsdtReferral
object
CRC
2 properties 2 required
Dependent
object
LOOP 2000C
11 properties 5 required
PriorAuthorization
object
Loop 2400 REF
2 properties 1 required
Payer
object
2 properties
ClaimAdjustment
object
CR1
2 properties 2 required
supervising
object
Loop: 2420D
20 properties 1 required
FormIdentification
object
LQ and FRM
3 properties 2 required
referring
object
Loop: 2420F
20 properties 1 required
billing
object
Loop: 2000A
20 properties 1 required
ClaimContractInformation
object
Loop 2300, Segment: CN1
6 properties 1 required
PatientConditionInformationVision
object
Loop 2300, Segment: CRC
3 properties 3 required
ServiceLineDateInformation
object
10 properties
ClaimNote
object
NTE
5 properties
OtherPayerBillingProvider
object
Loop 2330G
2 properties 2 required
ContactInformationOrderingProvider
object
PER
5 properties 1 required
ConditionIndicatorDurableMedicalEquipment
object
CRC
3 properties 2 required
ServiceLineProvider
object
22 properties 1 required
rendering
object
Loop: 2420A
20 properties 1 required
ClaimSupplementalInformation
object
PWK and REF
15 properties
PurchasedServiceInformation
object
2 properties 2 required
Failure
object
2 properties
DurableMedicalEquipmentCertificateOfMedicalNecessity
object
PWK
1 property 1 required
ReferenceIdentification
object
3 properties 2 required
DurableMedicalEquipmentCertification
object
CR3
2 properties 2 required
CompositeDiagnosisCodePointers
object
SVC107
1 property 1 required
EditResponse
object
13 properties
OtherPayerServiceFacilityLocation
object
Loop 2330E
1 property 1 required
OtherPayerRenderingProvider
object
Loop 2330D
2 properties 1 required
OtherPayerName
object
Loop: 2330B
11 properties 3 required
OtherSubscriberName
object
Loop: 2330A
9 properties 4 required
ClaimAdjustmentDetails
object
CAS
3 properties 2 required
ResponseMeta
object
meta data about the request
5 properties
OtherSubscriberInformation
object
Loop 2320
21 properties 7 required
PayToPlan
object
2010AC
7 properties 5 required
HealthCareInformation
object
HI
2 properties 2 required
AmbulanceTransportInformation
object
CR1
5 properties 2 required
ordering
object
Loop: 2420E, Setting ProviderType equal to OrderingProvider is deprecated, please use ClaimInformation.serviceLines.orderingProvider
20 properties 1 required
OtherPayerReferringProvider
object
Loop 2330C
1 property 1 required
ReportInformation
object
3 properties 2 required
ClaimReference
object
Collection of info specific to a given claim
9 properties
DrugIdentification
object
LOOP 2410
6 properties 4 required
DurableMedicalEquipmentService
object
SV5
4 properties 4 required
SpinalManipulationServiceInformation
object
Loop 2300, Segment: CR2
3 properties 1 required
Receiver
object
Loop: 1000B
1 property 1 required

Specification

The full machine-readable OpenAPI contract behind this narrative.

Source

optum-professional-claims-api-openapi.yml Raw ↑

Other APIs Optum publishes across the network.

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Optum Ambulance Fee Schedule APIs API
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Optum Anesthesia Fee APIs API
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Optum APC Calculator APIs API
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Optum APC Cross Codes APIs API
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Optum Apip API
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Optum Application.wadl API
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Optum Attachment API
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Optum Attachment Document API
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Optum Attachment Status API
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Optum Attachment Submission API
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#Professional Claims
← Back to O APIs
API Details
ID
optum:optum-professional-claims-api
Base URL
https://apigw.optum.com/medicalnetwork/
Docs
https://developer.optum.com/eligibilityandclaims
Provider
Optum
APIs.io →  GitHub →
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