Optum

Optum Claim Review API

The Claim Review API from Optum — 1 operation(s) for claim review.

Documentation GitHub OpenAPI

Operations 2

GET /claims5x Get Claims Information #

POST /claims5x Get Claims Responses #

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OpenAPI Specification

openapi: 3.2.0
info:
  title: Optum Real-Time eContent Web services Claim Review API
  description: Optum® Real-Time eContent web services provides access to both ondemand medical coding data and Optum coding tool logic required by your applications. The information you or your clients need is delivered to your application in real time, when you need it, and customized to how you want it displayed. Optum Real-Time eContent service provides access to the content of 37 printed coding resources and proprietary data and offers the power of the Optum CodeLogic™ search engine.
  contact:
    name: Ken Kracker
    email: ken.kracker@optum.com
  version: 1.0.0
servers:
- url: sandbox-apigw.optum.com/ci/rtec/v1/ws
security:
- bearerAuth: []
tags:
- name: Claim Review
paths:
  /claims5x:
    get:
      tags:
      - Claim Review
      summary: Get Claims Information
      operationId: getClaims
      responses:
        '200':
          description: Successful Response
          content:
            application/xml:
              schema:
                type: string
              example: "<?xml version=\"1.0\" encoding=\"UTF-8\"?>\n<claims>\n  <claim id=\"1\">\n    <claim-line diagnostic-type='icd10cm'>\n      <service-begin-date>2009-07-16</service-begin-date>\n      <diagnostic-code>E10.9</diagnostic-code>\n      <diagnostic-code>E10.19</diagnostic-code>\n      <modifier>21</modifier>\n      <modifier>51</modifier>\n      <procedure-code>13100</procedure-code>\n    </claim-line>\n    <claim-line diagnostic-type='icd10cm'>\n      <service-begin-date>2009-07-16</service-begin-date>\n      <diagnostic-code>E10.9</diagnostic-code>\n      <diagnostic-code>250.01</diagnostic-code>\n      <modifier>21</modifier>\n      <modifier>51</modifier>\n      <procedure-code>13100</procedure-code>\n      <place-of-service>11</place-of-service>\n      <units>1</units>\n    </claim-line>\n    <birth-date>2009-07-16</birth-date>\n    <service-date>2009-07-16</service-date>\n    <gender>M</gender>\n    <payer>10102</payer>\n    <taxonomy>208600000X</taxonomy>\n  </claim>\n</claims>"
        '401':
          description: Not Authorised
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimResponses'
              example:
                timestamp: '2022-07-06T16:34:39.385Z'
                error: Unauthorized
                status: 401
    post:
      tags:
      - Claim Review
      summary: Get Claims Responses
      operationId: process
      requestBody:
        description: Term Search Request.
        content:
          application/xml:
            schema:
              $ref: '#/components/schemas/ClaimResponses'
            examples:
              Claim Request:
                description: Claim Request
                value: "<?xml version=\"1.0\" encoding=\"UTF-8\"?>\n<claims>\n  <claim id=\"1\">\n    <claim-line diagnostic-type='icd10cm'>\n      <service-begin-date>2009-07-16</service-begin-date>\n      <diagnostic-code>E10.9</diagnostic-code>\n      <diagnostic-code>E10.19</diagnostic-code>\n      <modifier>21</modifier>\n      <modifier>51</modifier>\n      <procedure-code>13100</procedure-code>\n    </claim-line>\n    <claim-line diagnostic-type='icd10cm'>\n      <service-begin-date>2009-07-16</service-begin-date>\n      <diagnostic-code>E10.9</diagnostic-code>\n      <diagnostic-code>250.01</diagnostic-code>\n      <modifier>21</modifier>\n      <modifier>51</modifier>\n      <procedure-code>13100</procedure-code>\n      <place-of-service>11</place-of-service>\n      <units>1</units>\n    </claim-line>\n    <birth-date>2009-07-16</birth-date>\n    <service-date>2009-07-16</service-date>\n    <gender>M</gender>\n    <payer>10102</payer>\n    <taxonomy>208600000X</taxonomy>\n  </claim>\n</claims>"
        required: true
      responses:
        '200':
          description: Successful Response
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimResponses'
              example:
                claimResponse:
                - edit:
                  - description: '[Pattern 8400] The diagnosis code(s) E1019 and E109 are invalid.'
                    editConflict: Invalid Diagnosis Code
                    editType: Review
                    mnemonic: ICD
                    line: 1
                  - description: '[Pattern 13248] The modifier code(s) 21 are invalid.'
                    editConflict: Invalid Modifier
                    editType: Review
                    mnemonic: IMO
                    line: 1
                  - description: '[Pattern 8400] The diagnosis code(s) 25001 and E109 are invalid.'
                    editConflict: Invalid Diagnosis Code
                    editType: Review
                    mnemonic: ICD
                    line: 2
                  - description: '[Pattern 13248] The modifier code(s) 21 are invalid.'
                    editConflict: Invalid Modifier
                    editType: Review
                    mnemonic: IMO
                    line: 2
                  claimId: '1'
        '400':
          description: Bad Request
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimResponses'
              example: "<?xml version=\"1.0\" encoding=\"UTF-8\" standalone=\"yes\"?>\n<notifications>\n    <error>Unexpected close tag &lt;/servce-date&gt;; expected &lt;/service-date&gt;.\n at [row,col {unknown-source}]: [48,41]</error>\n</notifications>"
        '401':
          description: Not Authorised
          content:
            application/json:
              schema:
                $ref: '#/components/schemas/ClaimResponses'
              example:
                timestamp: '2022-07-06T16:34:39.385Z'
                error: Unauthorized
                status: 401
components:
  schemas:
    ClaimResponses:
      required:
      - claimResponse
      type: object
      properties:
        claimResponse:
          type: array
          xml:
            name: claim-response
          items:
            $ref: '#/components/schemas/ClaimResponse'
      xml:
        name: claim-responses
    ClaimResponse:
      type: object
      properties:
        edit:
          type: array
          items:
            $ref: '#/components/schemas/ClaimLineEdit'
        claimId:
          type: string
          xml:
            name: claim-id
            attribute: true
    ClaimLineEdit:
      required:
      - description
      - editConflict
      - editType
      - mnemonic
      type: object
      properties:
        description:
          type: string
        editConflict:
          type: string
          xml:
            name: edit-conflict
        editType:
          type: string
          xml:
            name: edit-type
        mnemonic:
          type: string
        line:
          type: integer
          format: int32
          xml:
            attribute: true
  securitySchemes:
    bearerAuth:
      type: http
      scheme: bearer
    ws_auth:
      type: oauth2
      flows:
        authorizationCode:
          authorizationUrl: https://idx.linkhealth.com/auth
          tokenUrl: https://idx.linkhealth.com/auth/token
          scopes:
            scope-1: required scope for API access
x-readme:
  explorer-enabled: true
  proxy-enabled: true