Optum Real (Medical) API

openapi: 3.2.0
info:
  description: The GraphQL Auth Referral Submission API allows users to search for providers, submit referrals, search referrals, and search prior authorizations using GraphQL queries and mutations.
  title: Auth Referral Submission API
  version: 1.0.0
servers:
- url: https://sandbox-apigw.optum.com
tags:
- name: Auth Referral Submission
paths:
  /oihub/patient/auth/referral/v1:
    post:
      security:
      - oAuth:
        - read_healthcheck
      operationId: authReferralSubmission
      tags:
      - Auth Referral Submission
      parameters:
      - name: providerTaxId
        in: header
        description: Provider Tax ID Number
        required: true
        schema:
          example: '123456789'
          type: string
      - name: x-optum-consumer-correlation-id
        in: header
        description: Unique UUID to track the transaction
        required: false
        schema:
          example: 4d4a8964-e5fa-42dc-a37d-12345789
          type: string
      - name: environment
        in: header
        description: Environment
        required: false
        schema:
          example: sandbox
          type: string
      requestBody:
        required: true
        content:
          application/json:
            schema:
              type: object
              required:
              - query
              description: GraphQL queries/mutations for Auth Referral Submission
              properties:
                query:
                  description: GraphQL query or mutation
                  type: string
                variables:
                  description: Variables for the GraphQL query/mutation
                  type: object
                  properties:
                    providerSearchInput:
                      properties:
                        searchType:
                          description: REQUESTING,SERVICING
                          example: SERVICING
                          type: string
                        provider:
                          $ref: '#/components/schemas/ProviderInput'
                        patient:
                          $ref: '#/components/schemas/PatientInput'
                        pagination:
                          $ref: '#/components/schemas/PaginationInput'
                        payerId:
                          description: payerId
                          example: '87726'
                          type: string
                      type: object
                      required:
                      - searchType
                      - provider
                      - patient
                      - payerId
                    referralSubmitInput:
                      properties:
                        requestingProvider:
                          $ref: '#/components/schemas/ReferralSubmitProviderInput'
                        patient:
                          $ref: '#/components/schemas/PatientInput'
                        service:
                          $ref: '#/components/schemas/ServiceInput'
                        servicingProvider:
                          description: Servicing provider information
                          $ref: '#/components/schemas/ReferralSubmitProviderInput'
                        payerId:
                          description: payerId
                          example: '87726'
                          type: string
                      type: object
                      required:
                      - requestingProvider
                      - patient
                      - service
                      - servicingProvider
                      - payerId
                    referralSearchInput:
                      properties:
                        patient:
                          $ref: '#/components/schemas/PatientInput'
                        serviceStartDate:
                          example: '2024-01-01'
                          type: string
                        serviceEndDate:
                          example: '2024-12-31'
                          type: string
                        status:
                          description: 'default: APPROVED'
                          example: ALL
                          type: string
                        pagination:
                          $ref: '#/components/schemas/PaginationInput'
                        payerId:
                          description: payerId
                          example: '87726'
                          type: string
                      type: object
                      required:
                      - patient
                      - serviceStartDate
                      - serviceEndDate
                      - payerId
                    priorAuthSearchInput:
                      properties:
                        serviceReferenceNumber:
                          description: PriorAuth unique case Id reference number.
                          example: AXXXXXX
                          type: string
                        corporateTin:
                          description: Corporate Tax Identification Number.
                          example: '123456789'
                          type: string
                        provider:
                          $ref: '#/components/schemas/PriorAuthSearchProviderInput'
                        member:
                          $ref: '#/components/schemas/PatientInput'
                        serviceSetting:
                          description: Filter by service setting type.
                          example: Inpatient
                          type: string
                        status:
                          description: Filter by case status.
                          example: Open
                          type: string
                        startDate:
                          description: Start date for the service period search (YYYY-MM-DD). Default will be current date.
                          example: '2025-07-19'
                          type: string
                        endDate:
                          description: End date for the service period search (YYYY-MM-DD). Default will be current date.
                          example: '2025-10-17'
                          type: string
                        payerId:
                          description: payerId
                          example: '87726'
                          type: string
                      type: object
                      required:
                      - corporateTin
                      - provider
                      - member
                      - payerId
                operationName:
                  description: Name of the GraphQL operation to execute (optional)
                  type: string
            examples:
              SearchProviders:
                summary: Search Providers
                value:
                  query: 'query SearchProviders($providerSearchInput: ProviderSearchInput!) { searchProviders(providerSearchInput: $providerSearchInput) { providers { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } uniqueProviderIdentifier providerType providerSpeciality { code description } gender distance handicapAccessible } pagination { totalRecords nextPageToken } } }'
                  variables:
                    providerSearchInput:
                      searchType: SERVICING
                      provider:
                        zip: '90210'
                        radius: 50
                        firstName: Dr. Carlos
                        lastOrOrgName: Rodriguez
                        npi: '9876543210'
                        taxId: '987654321'
                        preferredLanguage: SPA
                        specialityCode: CARD
                        gender: M
                      patient:
                        firstName: Alice
                        lastName: Johnson
                        id: '1234567890'
                        dateOfBirth: '1990-12-31'
                        groupNumber: GRP321
                      pagination:
                        nextPageToken: '2'
                      payerId: '87726'
                  operationName: SearchProviders
              SubmitReferral:
                summary: Submit Referral
                value:
                  query: 'mutation SubmitReferral($referralSubmitInput: ReferralSubmitInput!) { submitReferral(referralSubmitInput: $referralSubmitInput) { referralId referralStatus payer { id name messages } requestingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } servicingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } patient { id firstName middleName lastName dateOfBirth groupNumber relationshipCode relationshipDesc } decisions { decisionType certificationAction reviewDecisionReason startDate endDate referralQuantity { quantity qualifier qualifierDesc remaining } } x12Response rejectionReasons { rejectionLevel reasonDescription rejectionCode followUpAction rejectionReason validRequestIndicator } } }'
                  variables:
                    referralSubmitInput:
                      requestingProvider:
                        npi: '1234567890'
                        taxId: '98765432'
                        zip: '90201'
                        firstName: Carlos
                        lastOrOrgName: Dr. Carlos Clinic
                        specialityCode: CARD
                        gender: M
                        city: Healthcare City
                        state: CA
                        radius: 50
                        contactName: Carlos Benito
                        phoneNumber: 555-222-3333
                        preferredLanguage: SPA
                      patient:
                        firstName: Alice
                        lastName: Johnson
                        id: '1234567890'
                        dateOfBirth: '1990-12-31'
                        groupNumber: GRP321
                      service:
                        diagnosisCodes:
                        - M79.3
                        referralQuantity:
                          quantity: 10
                          qualifier: VS
                        startDate: '2025-01-01'
                        endDate: '2025-01-01'
                        comment: Patient requires physical therapy for knee pain
                      servicingProvider:
                        npi: '1234567890'
                        taxId: '98765432'
                        zip: '90201'
                        firstName: Carlos
                        lastOrOrgName: Dr. Carlos Clinic
                        specialityCode: CARD
                        gender: M
                        city: Healthcare City
                        state: CA
                        radius: 50
                        contactName: Carlos Benito
                        phoneNumber: 555-222-3333
                        preferredLanguage: SPA
                      payerId: '87726'
                  operationName: SubmitReferral
              SubmitReferralRejection:
                summary: Submit Referral Rejection
                value:
                  query: 'mutation SubmitReferral($referralSubmitInput: ReferralSubmitInput!) { submitReferral(referralSubmitInput: $referralSubmitInput) { referralId referralStatus payer { id name messages } requestingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } servicingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } patient { id firstName middleName lastName dateOfBirth groupNumber relationshipCode relationshipDesc } decisions { decisionType certificationAction reviewDecisionReason startDate endDate referralQuantity { quantity qualifier qualifierDesc remaining } } x12Response rejectionReasons { rejectionLevel reasonDescription rejectionCode followUpAction rejectionReason validRequestIndicator } } }'
                  variables:
                    referralSubmitInput:
                      requestingProvider:
                        npi: '1234567890'
                        taxId: '98765432'
                        zip: '90201'
                        firstName: Carlos
                        lastOrOrgName: Dr. Carlos Clinic
                        specialityCode: CARD
                        gender: M
                        city: Healthcare City
                        state: CA
                        radius: 50
                        contactName: Carlos Benito
                        phoneNumber: 555-222-3333
                        preferredLanguage: SPA
                      patient:
                        firstName: Alice
                        lastName: Johnson
                        id: '1234567890'
                        dateOfBirth: '1990-12-31'
                        groupNumber: GRP321
                      service:
                        diagnosisCodes:
                        - M79.3
                        referralQuantity:
                          quantity: 10
                          qualifier: VS
                        startDate: '2025-01-01'
                        endDate: '2025-01-01'
                        comment: Patient requires physical therapy for knee pain
                      servicingProvider:
                        npi: '1234567890'
                        taxId: '98765432'
                        zip: '90201'
                        firstName: Carlos
                        lastOrOrgName: Dr. Carlos Clinic
                        specialityCode: CARD
                        gender: M
                        city: Healthcare City
                        state: CA
                        radius: 50
                        contactName: Carlos Benito
                        phoneNumber: 555-222-3333
                        preferredLanguage: SPA
                      payerId: '87726'
                  operationName: SubmitReferral
              SearchReferrals:
                summary: Search Referrals
                value:
                  query: 'query SearchReferrals($referralSearchInput: ReferralSearchInput!) { searchReferrals(referralSearchInput: $referralSearchInput) { referrals { referralId referralStatus referralStatusCode requestingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } providerSpeciality { code description } } servicingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } providerSpeciality { code description } } service { diagnosisCodes referralQuantity { quantity qualifier qualifierDesc remaining } startDate endDate comment } rejectionResponse { rejectionLevel reasonDescription rejectionCode followUpAction rejectionReason validRequestIndicator } } pagination { totalRecords nextPageToken } } }'
                  variables:
                    referralSearchInput:
                      patient:
                        firstName: Alice
                        lastName: Johnson
                        id: '1234567890'
                        dateOfBirth: '1990-12-31'
                        groupNumber: GRP321
                      serviceStartDate: '2024-01-01'
                      serviceEndDate: '2024-12-31'
                      status: ALL
                      pagination:
                        nextPageToken: '2'
                      payerId: '87726'
                  operationName: SearchReferrals
              SearchPriorAuths:
                summary: Search Prior Auths
                value:
                  query: 'query SearchPriorAuths($priorAuthSearchInput: PriorAuthSearchInput!) { searchPriorAuths(priorAuthSearchInput: $priorAuthSearchInput) { caseSummary { serviceReferenceNumber memberID memberFirstName memberLastName serviceSetting placeOfService serviceDates caseStatus overallCoverageStatus } caseDescription { caseSearchMessages caseDetail { serviceReferenceNumber caseStatus caseStatusReason primaryCarePhysician advanceNotifyDateTime admissionNotifyDateTime expectedServiceStartDate expectedServiceEndDate actualServiceStartDate actualServiceEndDate } coverageStatus { overallCoverageStatus procedureCode description coverageStatus decisionDate geneticMolecularTestCode geneticMolecularTestReviewType } clinicalNotes { createdTime createdBy noteText } patientDetails { id firstName middleName lastName dateOfBirth groupNumber relationshipCode relationshipDesc product effectiveDate terminationDate insuranceType verbalLanguagePreference writtenLanguagePreference informationalMessage } submittingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } admittingAttendingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } orderingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } facilityDetails { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } coverage } serviceDetails { placeOfService serviceDescription serviceDetails } facilityServiceDetails { startDate endDate serviceDescription isPatientAdmitted expectedAdmissionDate expectedDischargeDate actualAdmissionDateTime isPatientDischarged dischargeDate dischargeLocation } diagnosisDetails { codePointer code description } procedureCodeDetails { codePointer code description coverageStatus servicingProvider { name firstName middleName lastName providerOrganizationName npi taxId contactName phoneNumber fax networkStatus address { addressLine1 addressLine2 city state zip zip4 } } serviceDetail expectedFromDate expectedToDate procedureUnitPerFrequencyCount procedureUnitOfMeasure procedureFrequency procedureUnitCount dmeProcurementType dmeTotalCost dmeClinicalIllnessDescText dmeSupplyDescText dmeEnternalFeedingSSONutrInd dmeFormulaNameText dmeMedicalConditionText } expeditedRequestReview initialContact { contactName phoneNumber fax } followUpContact { contactName phoneNumber fax departmentType contactRoleType emailAddress medicalRecordNumber memberPhone } } } }'
                  variables:
                    priorAuthSearchInput:
                      serviceReferenceNumber: AXXXXXX
                      corporateTin: '123456789'
                      provider:
                        firstName: Dr. Carlos
                        lastOrOrgName: Rodriguez
                        address:
                          addressLine1: 1234 Street
                          addressLine2: Building A
                          city: Healthcare City
                          state: AZ
                          zip: '90210'
                          zip4: '0001'
                      member:
                        firstName: Alice
                        lastName: Johnson
                        id: '1234567890'
                        dateOfBirth: '1990-12-31'
                        groupNumber: GRP321
                        stateCode: AZ
                        zipCode: '90210'
                      serviceSetting: Inpatient
                      status: Open
                      startDate: '2025-07-19'
                      endDate: '2025-10-17'
                      payerId: '87726'
                  operationName: SearchPriorAuths
      responses:
        '200':
          description: "<strong>SearchProviders</strong>\n<ul>\n  <li><strong>MISSING_REQUIRED_FIELD</strong>\n    <ul>\n      <li>Missing mandatory field: XXXX</li>\n    </ul>\n  </li>\n  <li><strong>INVALID_SEARCH</strong>\n    <ul>\n      <li>At least one provider detail must be provided</li>\n    </ul>\n  </li>\n  <li><strong>BACKEND_VALIDATION_FAILED</strong>\n    <ul>\n      <li>Invalid or missing fields: XXXX</li>\n      <li>PCP not available for this member</li>\n      <li>Requested tin is not matching with Primary care provider tin</li>\n      <li>No provider found for the given search criteria</li>\n      <li>This Service does not support the selected member plan or platform</li>\n      <li>Member lookup failed. Verify input</li>\n      <li>No Member Policy found for the member</li>\n      <li>The member’s plan does not have an active policy</li>\n      <li>This service is not supported for NICE-migrated members</li>\n      <li>This service does not support delegated members.</li>\n      <li>Primary care provider is not found for the member</li>\n      <li>Primary care provider Tin is empty or not applicable</li>\n      <li>Derived Line of Business is blank</li>\n    </ul>\n  </li>\n</ul>\n\n<strong>SubmitReferral</strong>\n<ul>\n  <li><strong>MISSING_REQUIRED_FIELD</strong>\n    <ul>\n      <li>Missing mandatory field: XXXX</li>\n    </ul>\n  </li>\n  <li><strong>INVALID_SEARCH</strong>\n    <ul>\n      <li>Invalid value for XXXX</li>\n    </ul>\n  </li>\n  <li><strong>BACKEND_VALIDATION_FAILED</strong>\n    <ul>\n      <li>Invalid or missing fields: XXXX</li>\n      <li>No Member Policy found for the member</li>\n      <li>The member's plan does not have an active policy</li>\n      <li>This member's plan does not require referrals</li>\n      <li>This service is not supported for NICE-migrated members</li>\n      <li>This service does not support delegated members</li>\n      <li>Primary care provider Tin is empty or not applicable</li>\n      <li>Requesting Provider tin is not matching with Pcp tin</li>\n      <li>No Provider found for the requesting provider combination</li>\n      <li>No Unique Provider found for the requesting provider combination</li>\n      <li>Valid address not found for the requesting provider</li>\n      <li>Valid contract not found for the requesting provider</li>\n      <li>No matching policies with plan benefits.</li>\n      <li>Multiple matching policies found.</li>\n      <li>No provider found for the servicing provider combination</li>\n      <li>No Unique Provider found for the serving provider combination</li>\n      <li>No exact match found for the diagnosis code: XXXX</li>\n      <li>Invalid diagnosis code provided: XXXX</li>\n      <li>This Service does not support the selected member plan or platform</li>\n      <li>Derived Line of Business is  blank</li>\n    </ul>\n  </li>\n</ul>\n\n<strong>SearchReferrals</strong>\n<ul>\n  <li><strong>MISSING_REQUIRED_FIELD</strong>\n    <ul>\n      <li>Missing mandatory field: XXXX</li>\n    </ul>\n  </li>\n  <li><strong>BACKEND_VALIDATION_FAILED</strong>\n    <ul>\n      <li>Invalid or missing fields: XXXXX</li>\n      <li>This Service does not support the selected member plan or platform</li>\n      <li>Member lookup failed. Verify input.</li>\n    </ul>\n  </li>\n</ul>\n\n<strong>PriorAuth Search</strong>\n<ul>\n  <li><strong>MISSING_REQUIRED_FIELD</strong>\n    <ul>\n      <li>Missing mandatory header field: XXXX</li>\n      <li>Missing mandatory field: XXXX</li>\n    </ul>\n  </li>\n  <li><strong>BACKEND_VALIDATION_FAILED</strong>\n    <ul>\n      <li>Provider not found for the requested corporateTin</li>\n      <li>Provider not found for the requested provider.firstName/provider.lastOrOrgName</li>\n      <li>No records found</li>\n      <li>Member not found</li>\n      <li>Service setting is invalid. Please update your request with one of the following - Inpatient, Outpatient Facility, Outpatient, or All and resubmit your request</li>\n      <li>Status is invalid. Please update your request with one of the following - Cancelled, Open, Closed or All and resubmit your request</li>\n      <li>corporateTin/provider.firstName/provider.lastOrOrgName is invalid, please provide a valid input</li>\n      <li>The case search results in excessive number of cases returned. Please refine the search criteria or date range</li>\n      <li>No Case Detail record found</li>\n    </ul>\n  </li>\n  <li><strong>CASE_SUMMARY_NOT_FOUND</strong>\n    <ul>\n      <li>Provider and Member SRN not found</li>\n    </ul>\n  </li>\n  <li><strong>INFORMATION</strong>\n    <ul>\n      <li>Multiple SRNs found for the requested details. For case details, include a SRN number on the request</li>\n    </ul>\n  </li>\n</ul>\n"
          content:
            application/json:
              examples:
                SearchProviders:
                  summary: Search Providers
                  value:
                    data:
                      searchProviders:
                        providers:
                        - name: John J Doe
                          firstName: John
                          middleName: J
                          lastName: Doe
                          providerOrganizationName: Dr. John Doe Clinic
                          npi: '1234567890'
                          taxId: '987654321'
                          contactName: Alison Johnson
                          phoneNumber: 555-222-3333
                          fax: 555-222-4444
                          networkStatus: IN_NETWORK
                          address:
                            addressLine1: 123 Healthcare Drive
                            addressLine2: Suite 200
                            city: Healthcare City
                            state: CA
                            zip: '90210'
                            zip4: '0001'
                          uniqueProviderIdentifier: enc_pvd_123456789abcdef
                          providerType: INDIVIDUAL
                          providerSpeciality:
                          - code: 207Q00000X
                            description: Family Medicine
                          gender: Male
                          distance: '2.5'
                          handicapAccessible: true
                        pagination:
                          totalRecords: '147'
                          nextPageToken: '3'
                SubmitReferral:
                  summary: Submit Referral
                  value:
                    data:
                      submitReferral:
                        referralId: REF123456789
                        referralStatus: APPROVED
                        payer:
                          id: PAY001
                          name: UnitedHealthcare
                          messages:
                          - Referral approved for 12 visits
                        requestingProvider:
                          name: John J Doe
                          firstName: John
                          middleName: J
                          lastName: Doe
                          providerOrganizationName: Dr. John Doe Clinic
                          npi: '1234567890'
                          taxId: '987654321'
                          contactName: Alison Johnson
                          phoneNumber: 555-123-4567
                          fax: 555-222-4444
                          networkStatus: IN_NETWORK
                          address:
                            addressLine1: 123 Medical Drive
                            addressLine2: Building A
                            city: Healthcare City
                            state: CA
                            zip: '90210'
                            zip4: '0001'
                        servicingProvider:
                          name: John J Doe
                          firstName: John
                          middleName: J
                          lastName: Doe
                          providerOrganizationName: Dr. John Doe Clinic
                          npi: '1234567890'
                          taxId: '987654321'
                          contactName: Alison Johnson
                          phoneNumber: 555-123-4567
                          fax: 555-222-4444
                          networkStatus: IN_NETWORK
                          address:
                            addressLine1: 123 Medical Drive
                            addressLine2: Building A
                            city: Healthcare City
                            state: CA
                            zip: '90210'
                            zip4: '0001'
                        patient:
                          id: '123456789'
                          firstName: Alice
                          middleName: A
                          lastName: Johnson
                          dateOfBirth: '1990-12-31'
                          groupNumber: GRP321
                          relationshipCode: '18'
                          relationshipDesc: SELF
                        decisions:
                        - decisionType: EVENT
                          certificationAction: A1
                          reviewDecisionReason: MEETS_CRITERIA
                          startDate: '2024-11-30'
                          endDate: '2024-11-30'
                          referralQuantity:
                            quantity: 12
                            qualifier: VS
                            qualifierDesc: visits
                            remaining: 8
                        x12Response: ISA*00*          *00*          *ZZ*SENDER         *ZZ*RECEIVER       *241010*1234*^*00501*000000001*0*P*:~
                        rejectionReasons:
                        - rejectionLevel: REFERRAL
                          reasonDescription: Insufficient medical documentation provided
                          rejectionCode: R001
                          followUpAction: RESUBMIT_WITH_DOCUMENTATION
                          rejectionReason: MISSING_DOCUMENTATION
                          validRequestIndicator: N
                SubmitReferralRejection:
                  summary: SubmitReferral Rejection
                  value:
                    data:
                      submitReferral:
                        referralId: ''
                        referralStatus: REJECTED
                        payer:
                          id: PAY001
                          name: UnitedHealthcare
                          messages:
                          - Referral denied - see rejection reasons
                        rejectionReasons:
                        - rejectionLevel: REFERRAL
                          reasonDescription: Insufficient medical documentation provided
                          rejectionCode: R001
                          rejectionReason: MISSING_DOCUMENTATION
                          followUpAction: RESUBMIT_WITH_DOCUMENTATION
                          validRequestIndicator: N
                SearchReferrals:
                  summary: Search Referrals
                  value:
                    data:
                      searchReferrals:
                        referrals:
                        - referralId: REF123456789
                          referralStatus: APPROVED
                          referralStatusCode: A1
                          requestingProvider:
                            name: John J Doe
                            firstName: John
                            middleName: J
                            lastName: Doe
                            providerOrganizationName: Dr. John Doe Clinic
                            npi: '1234567890'
                            taxId: '987654321'
                            contactName: Alison Johnson
                            phoneNumber: 555-222-3333
                            fax: 555-222-4444
                            networkStatus: IN_NETWORK
                            address:
                              addressLine1: 123 Healthcare Drive
                              addressLine2: Suite 200
                              city: Healthcare City
                              state: CA
                              zip: '90210'
                              zip4: '

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# Full source: https://raw.githubusercontent.com/api-evangelist/optum/refs/heads/main/openapi/optum-auth-referral-submission-api-openapi.yml