Integrated Rules Institutional FAQs

The Integrated Rules Institutional API is an enabling tool for making complex provider claims more accurate, and more likely to be accepted and adjudicated by the pay.

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The Integrated Rules Institutional API requires the use of the Institutional Claims API for submission of claims to the payer; or, if you have another workflow for claims submissions, you may use that instead.

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See the API Examples section on the left panel in the developer portal.

How do I submit my edited claims?

Please see example in Submit Edited Claims.

What do Integrated Rules Institutional submissions look like?

Please see example in Integrated Rules Institutional Submission and Response.

Does the Integrated Rules Institutional API have a Submission endpoint?

No, it does not. When you finish evaluating and correcting your claim through the Integrated Rules Institutional API, you can submit your corrected claim through the standard Institutional Claims API institutionalclaims/v1/submission endpoint or through your accustomed workflow for that task.

The Integrated Rules Institutional API is designed as a complementary product for use with the Institutional Claims API.

How do Raw-X12 Validation requests and responses work?

See X12 EDI 270 Request & 271 Response.

What is the biggest value-add from using this API?

See biggest value-add from using this API.

Does your API support HIPAA Validations?

See HIPAA Validations support.

If you use a different claim submission workflow, you can also submit your claim that way. Consult your Optum representative for more information.

What is the difference between an Institutional claims and a Professional claims?

See difference between a Professional claim and an Institutional claim?.

What's the difference between this API and the regular Institutional Claims API?

See difference between this API and the regular Institutional Claims API.

Are there guidelines for predicting the rate of unique claims submitted for a practice?

Rates of unique claims are isolated to each individual provider. Every provider is different. Whenever you render a medical service, file a claim.

The Institutional Claims API FAQs topic discusses about many informative items that describe the various features and reasons to use the Institutional Claims API.

How do Raw-X12 Validation requests and responses work?

Please see example in X12 EDI 270 Request & 271 Response.

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When your EDI formatted request is corrected and validated, use your normal claim submission workflow to submit the claim. The Institutional Claims v1 API does not directly support the X12 EDI submissions.

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