Glossary
This section includes description for the glossary of terms.
ACN
Attachment Control Number.
Active Coverage
This indicates that the service is covered additional details would need to be obtained from the details.
AD
Admitting.
Additional Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Alternative Payer Name
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
Attachment Control Number.
Active Coverage
This indicates that the service is covered additional details would need to be obtained from the details.
AD
Admitting.
Additional Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Alternative Payer Name
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
This indicates that the service is covered additional details would need to be obtained from the details.
AD
Admitting.
Additional Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Alternative Payer Name
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
Admitting.
Additional Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Alternative Payer Name
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Alternative Payer Name
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
The Alternative Payer Name is typically another name the payer may have had or another name they may be known as.
ANSI
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
American National Standards Institute.
API
Optum APIs for the next generation
of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
These are the primary factors that should be considered. Additionally, verification of the services are being rendered by an in-network or out-of-network physician can affect the customer's responsibility.
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us.
ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically
found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or
co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer.
If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
Optum APIs for the next generation of healthcare applications!
- Medical Network Eligibility V3 API: Provides complete patient profile and benefits information to support for delivering healthcare with more efficient and accurate reimbursement.
- Care Cost Estimator API: Out-Of-Pocket Estimation API service used for both Estimation and Accumulation of Benefits.
- Vaccination Data Intake Service API: Gives immunization providers and authorized users a simple way to add data to the Vaccination Record Service and issue certified vaccination credentials.
The Vaccination Data Intake API is a companion to the Vaccination Credential Sharing API and Vaccination Credential Verification API for secure sharing and verification of the vaccination record. - Vaccination Credential Sharing and Verification APIs: Are Vaccination Credential Initiative, and allow authorized client applications to request and verify immunization credentials in the form of 'Smart Health Cards' from the Optum Vaccination Record solution.
- Professional Claims API and the Institutional Claims API:
- Allow healthcare providers and institutions to submit healthcare claims for a service or encounter.
- Claims Status API: Used by the submitter of a medical claim to determine the status of any previously submitted Institutional or Professional claim.
Benefit Amount
This is Patient's responsibility. The meaning of this value depends on the `benefitsInformation`.
Benefits Description
A written determination that an applicant is eligible for healthcare aid or subsistence aid or both.
BI
Billing
Benefits Information Codes
This code is used to identify the eligibility or benefit information. This may be the eligibility status of the individual or the benefit related category. A list of the codes are: A, B, C, G, J, or Y
- A – Co-Insurance
- B – Co-Payment
- C – Deductible
- G – Out of Pocket (Stop Loss)
- J – Cost Containment
- Y – Spend Down
Bundled Cost
A bundled cost is the price that a provider charges for a given service.
CCN
Claim Control Number.
CI
Commercial Insurance.
Claim Status
Checks the status of a claim in the payer’s system. If a provider has not received a payer report on a claim, or if they have not received payment, they run a claim status request to find out the most recent status of that claim. Supports Professional and Institutional claims.
ClaimInformation
A key block of medical coding information that defines the actual procedures and services rendered for the medical encounter. It contains other JSON blocks including the serviceLines objects that contain the professionalService line item charges and diagnosis information.
ClaimReference
Contains important values, such as the payerId, customerClaimNumber, the claimType, and other values that mostly will be managed programmatically.
ClaimResponses and Reports
A fetching tool for claims information from your mailbox. Supports Professional and Institutional claims.
CLIA
Clinical Laboratory Improvement Amendment.
CMS
Centers for Medicare and Medicaid.
COB
Coordination of Benefits.
Co-Insurance
Co-insurance represents the patient's portion of responsibility for a benefit, and is represented as a percentage in benefitPercent. The co-insurance percentage is typically found in a fee for service environment and is based on a percentage of the total amount the provider would be paid for the service(s). Since the actual amount that would be paid to the provider may not be known until after the claim has been processed, a percentage is used, rather than an actual dollar amount. For example, a patient may have a 20% co-insurance for a physician office visit if the provider is in the plan that the patient belongs to, or patient may have a 40% co-insurance for a physician office visit if the provider is not in the plan that the patient belongs to. The provider may calculate an estimated amount to collect from the patient or may wait until after the claim has been processed to collect the actual amount from the patient (requirements may vary from plan to plan). If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitPercent.
Co-Payment
Co-payment represents the patient's portion of responsibility for a benefit and is represented as a dollar amount in benefitAmount. The co-payment amount is typically a fixed amount and is customarily collected upon receipt of service (however the requirements may vary from plan to plan). For example, a patient may have a $10 co-payment for a physician office visit or a $50 co-payment for an Emergency Room visit. If the patient's portion of responsibility for a benefit is nothing, "0" is to be placed in benefitAmount.
ConnectCenter (aka Legacy Relay Health (LRH) Payer List
A portal for our customers who are utilizing our Clearance or Assurance solutions. When you log into ConnectCenter it does show all payer lists so that may be what you are looking for. If you are using our APIs for Claims and Eligibility you will want to use the ConnectCenter payer list.
ControlNumber
A single arbitrary value that the requestor (Providers and often Payers, originate) defines in the initial Eligibility API transaction request. All parties to the Eligibility transaction refer to this number to ensure accurate responses and completion of the exchange. The `controlNumber` is a random or auto-generated number that you create and send to us for each transaction. That unique number helps with any troubleshooting and tracking of the transaction when you are 'Live' with us. ControlNumbers must be defined as a 9-digit unsigned numeric value.
CPID
Claim Payer Identification (for claims process only). This unique identifier is setup to process claims with payers. Per the Claim type column, you can identify if it is a Professional CPID or an Institutional CPID. You should use that for submitting the claim, the `tradingPartnerServiceId` field.
CSA
Customer service announcements.
DCN
Document Control Number.
Deductible
Total amount of the patient's portion of responsibility for a benefit and is represented as a dollar amount in EB07. The deductible amount is typically found in a fee for service environment and is based on the total amount the patient will have to pay before their benefits begin (which may then require co-insurance or co-payment). If the patient's portion of responsibility for a benefit is nothing, "0" is to be returned. The deductible information would be returned by STC and should be applied based on the services that are rendered, what STC code they would fall under and the time qualifier returned by the payer. If you have separate deductibles for in-network and out-of-network care, the amount you have already paid toward your in-network deductible does not count toward your out-of-network deductible. These would be separate amounts and would not count towards each other.
Dependent
Dependent of the policy holder (information about the insurance policy holder's dependent who received the medical services.
Dependent Coverage
Dependent coverage represents coverage for family members of the policyholder, such as spouses, children, or partners. The response contains benefits information for the individual and for the family. The dependents fall under the family information.
DiagnosisCode
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
Diagnosis Code, indicates a code from a specific industry code list. See annotation in OpenAPI spec.
DiagnosisTypeCode
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
Diagnosis Type Code, example: ABK. The listed diagnosis is the patient diagnosis. See annotation in OpenAPI spec.
Diagnosis Code Pointer
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider.
They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of
responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the
individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
This information is common across the medical industry and can be found on many crosswalks or sites.
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago
The Diagnosis Pointer relates to the reason for which the service was performed. For more information, see.
DMERC
Durable Medical Equipment Regional Carrier Certificate.
DRG
Diagnosis Related Group.
DMG
Demographic information.
DOB
Date-of-Birth.
DOS
Date-of-Service: date of provider service to the subscriber.
EDI
Electronic data interchange.
ERA
Electronic Remittance Advice.
EntityIdentifier Attribute
Describes the information receiver that sent the Eligibility request, in this case, a Provider. They will typically be receiving the patient's insurance information as the response to their request.
EOB
Explanation of Benefits.
Episode
An episode of care includes all the services provided to a patient to treat a clinical condition or procedure. The services included in an episode of care occur within a specific period of time and from a range of organizations that make up an integrated system.
ESRD
End Stage Renal Disease.
EntityType
Will always be either a Person or a Non-Person entity. In this example, the submitting provider's NPI follows.
ETIN
Electronic Transmitter Identification Number.
Family Indicator
The primary indicator of coverage for all dependents unless otherwise specified by the payer. It might also return spouse or child. Additionally, there are some payers in which each individual member would have a unique ID. The “dependents” of the policy would have a unique member ID associated with them that should be sent to the payer.
HCI
Health Care Information.
G
HCPCS
Healthcare Common Procedure Coding System: defines reference codes for items and services provided in the delivery of healthcare.
HIPAA
Health Insurance Portability and Accountability Act.
Healthcheck
The `/healthcheck` endpoint verifies that the operating status of the Optum APIs is optimal and the APIs are running and accessible.
- status: "OK" for successful health check
ICN
Internal Control Number.
IDCard
The `idCard` is used when the Identity Card Number is different than the Member Identification Number. This is mainly prevalent in the Medicaid environment.
InPlanNetworkIndicator
In the API response, the payer will return a `inplanNetworkIndicator`; the in-network and out-of-network indicators on the transaction only indicate how the benefits should be applied in those specific situations for those service type codes. This can be used with the associated STC in the same object.
InPlanNetworkIndicator Values
- ’W’: Not Applicable (benefit applies to both In-Network and Out-of-Network providers)
- 'Y': In-Network (benefit is only for In-Network providers);
- 'N': Out-of-Network (benefit is only for Out-of-Network providers);
- ‘U’: Unknown (benefit cannot be used in calculations because it is not known if it is for In-Network or Out-of-Network);
Limitations
This indicates that the Individual in-network Orthodontics benefits are limited to $2000 for the remaining coverage dates.
Member ID
Member ID is the ID present on the insurance ID card. We advise you collect a copy of the member ID card at the time of service to confirm this information.
NAIC
National Association of Insurance Commissioners.
NCCI
National Correct Coding Initiative.
NPI
National Provider ID number for the submitting provider.
NUBC
National Uniform Billing Committee.
Optum Payer List
Optum Payer List (formerly, Change Healthcare, also internally known as Legacy Change, Emdeon, or Ark) is for our Submitters who are given a 9-digit submitter ID, and typically do not utilize APIs to submit their transactions. If you have a 6-digit submitter ID, use the ConnectCenter payer ID. Each of these payer lists represents different products or services that customers can purchase from Optum. There are plans to consolidate all of the payer lists but that will not be available for some time. The payer lists may have some overlap but customers should only use the payer lists for the products/services they are contracted or testing with.
Other Payer
This indicates that another payer may provide additional coverage for this member. In the sandbox, this is provided for reference of what the field would look like in a response.
Out-of-Pocket
(Stop Loss) represents the maximum amount of the patient's portion of responsibility before a benefit is covered with no additional payments from the patient, up to the maximum covered by the health plan. The Out of Pocket (Stop Loss) amount typically represents the combined total amount of deductible and co-insurance payments made by the patient. Some health plans have Out of Pocket (Stop Loss) amount for the individual patient and a higher amount for the entire family.
Pagination
Works with the query parameters size and page. Its maximum size is 1000. Page numbering starts at page 0.
ParCode
An access code required to view any additional information about payers, such as the parStatus in the Payer Finder user interface (UI) and API. Contact support for an access code.
ParStatus
An indication of whether or not a provider agrees to participate in the Medicare program and agrees to always accept the Medicare assignment for services rendered to Medicare beneficiaries.
Payer
Insurance company where the claim is going to.
Payer ID
Unique ID number that is assigned to an insurance company for the purpose of transmitting provider claims electronically. It can be found on the back of the insurance card. If it is not available, you can use the Realtime Payer ID.
PHI
Personal health information.
PMI
Personal medical information.
Policy Number
The policy number is typically the group number.
Procedure Modifier
Required when a modifier clarifies/improves the accuracy of the associated procedure code, the modifier is available and when the information receiver believes that the information source supports this high-level of functionality.
Provider
The provider involved with the medical claim. The `provider` object and its accompanying information describe the information receiver in the EDI standard documentation.
ProviderType
The Claims has the following provider types:
- “BillingProvider” (Loop 2010AA) – One who gets paid
- “ReferringProvider” (Loop 2310A) – One who directs the patient for care to the provider rendering the services being reported
- “RenderingProvider” (Loop 2310B) – One who performs the service
- “OrderingProvider” (Loop 2420E) – One who requested the services or items being reported on this service line. For example, provider ordering diagnostic tests and medical equipment or supplies
- “SupervisingProvider” (Loop 2310D) – Required when the rendering provider is supervised by a physician
QMB
Qualified medicare beneficiary.
R5 File
Provides payment and denial information from the payer. This report is an explanation of the claim payment sent by the payer and can be translated into JSON.
Realtime Payer ID
Used by Eligibility or Claim status.
ReassociationKey
A tracking number associated with the eligibility transaction so that we can look up the transaction being sent.
Receiver
Payer.
Required
The Required field indicates mandatory information.
REST API
Revenue Performance Advisor Payer List
Revenue Performance Advisor (known internally as RPA or Capario) Payer List is another product that has a specific payer list for users of that product. This is a payer list for customers who are sending attachments through Optum (formerly, Change Healthcare). These customers use an 8-digit submitter number.
Rural FQHC
Rural Health Clinics and Federally Qualified Health Centers.
SBC
Summary of benefits and coverage.
ServiceLines and ServiceDate
ServiceLines is an array of one or more medical services, procedures, or products for the encounter each of which, is specified as a serviceDate record in the array.
ServiceTypeCode
`ServiceTypeCode` is used to identify business groupings for healthcare services and benefits. Include the `serviceTypeCode` in the API request body, and then submit to payers on an eligibility and benefit inquiry transaction to get the patient’s eligibility and benefit details. The `serviceTypeCode` consists of `value` and `valueType`. Here is a complete list of service codes. serviceTypeCode '30' is most commonly used and provides general benefit information in the response. Depending on your need for specific eligibility information, the service type code might change.
Situational
Specific information may be you can included or omitted depending on the individual encounter.
StatusCode Attributes
Our Attachments Status APIs support a series of standard responses, called [statusCodes](doc:use-the-test-payers-in-the-sandbox-api#statuscode-responses) to show various results from submitted attachment transactions. For more information, see What do statusCode attributes mean?
SubmitterTransactionIdentifier
Used by Optum support team for troubleshooting purpose.
Subscriber
Medical insurance policy holder; includes the patient's insurance member ID and insurance policyNumber. The `subscriber` object is required when the subscriber is the patient.
SDK
A Software Dev Kit lets developers test applications before deploying on the production server.
Submitter
Provider submitting the claim; identification of the provider, including information, such as the organizationName.
Submitter ID
The submitter is your account number with Optum used to identify transactions routing to and from specific customers. A submitter ID is assigned to any entity submitting healthcare transactions to a payer. The submitter ID is one of the IDs used to identify transactions routing to and from specific customers. The submitter ID is an internal ID used by Optum. If your child accounts are submitting healthcare transactions to a payer OR if you want to keep those sub-accounts separate, they would each get their own submitter ID too.
Time Qualifier Code/Time Qualifier
The `timeQualifierCode` qualifies the time period for coverage. The `timeQualifier` is the actual value. Refer to Time Qualifier Reference.
Token
A hashed alphanumeric representation of sensitive data, such as a authorization token.
TraceID
A unique 128-bit UUID value (as an example, `3ba21288-3f65-11eb-a512-6ab12069ade5`) that Optum returns to the submitter as an acknowledgement when they receive every new attachments transaction. A traceId can also be retrieved by calling the metadata endpoint.
TradingPartner
Represents one or more file owners and payers.
TradingPartnersServiceID
The Payer ID (a number you will find on your insurance card). This is required to request benefit information from an insurance carrier. This will vary based on the payer you want to connect to. Here is a list of test Trading Partner Service IDs (either the CPID for claim submissions or the Real-Time Payer ID for eligibility transactions). For more information, see What is tradingPartnerServiceId.
TrackingNumber
The `trackingNumber` field is a tracking value that you can use at your discretion. It will accept any value and is not required. It exists so that you can link the 277 response back to your original request, and the payer will always echo this value back exactly as you sent it.
UMO
Utilization Management Organization.
VCI
Vaccination Credential Initiative, a cross-industry consortium that includes Optum.
X3 File
Returns the solicited claim status x12 raw data that matches exactly what is returned by the payer and can be translated into JSON. This file is received from payers when claim status is requested and not returned in real time.
For an alphabetical list of topics, see Quick Reference
Updated about 2 months ago