Optum API
If you’re a clinic, provider group, or a business running revenue cycle operations, integrating your tech stack with Optum can let you pull real-time authorizations and visit statuses, push EHR schedules into EVV, and tie verified visits directly to Medicaid reimbursement—especially helpful for Mass
What is Optum?
Optum (a UnitedHealth Group company) provides payer and health system technology spanning authorization management, eligibility verification, provider directory and enrollment, claims submission and remittance, analytics, and in some state programs, EVV connectivity for home and community-based services. Optum’s developer resources include services for claims and remittances (EDI 837/835), eligibility (270/271), and prior authorizations, alongside portals used by providers to manage EVV visits and reimbursement tasks.
Core product areas include:
- Electronic Visit Verification (mobile/telephony and aggregator connections, where enabled by the program)
- Authorization management (prior auths, service codes, units)
- Eligibility verification and payer program enrollment
- Provider directory, NPIs, and enrollment data
- Claims submission and remittance retrieval for Medicaid/MCO
- Compliance reporting for visit documentation and reimbursement
Common data entities:
- Members/Patients (Medicaid beneficiaries)
- Providers (clinics, groups, caregivers, billing providers)
- Visits (EVV check-in/out, service codes, tasks, verification metadata)
- Authorizations (payer/program, service code, units, validity dates)
- Payers/Programs (e.g., MassHealth Medicaid)
- Schedules and assignments
- Exceptions (late/missing events, GPS mismatch, overlapping visits)
- Claims (837P/I service lines referencing verified visits)
- Remittances (835 summaries for reconciliation)
The Optum Integration Challenge
Organizations rely on Optum daily, but turning portal-based workflows into automated pipelines is hard:
- Program- and payer-specific rules: Each Medicaid program may require distinct service codes, modifiers, and EVV validation logic
- Enterprise security: SSO/MFA and network controls complicate headless automation
- Portal-first delivery: Key EVV and authorization handling lives in web apps or batch exports, not unified public APIs
- EDI/SFTP interfaces and timing: 837/835 batching constraints and daily submission windows must be respected
- Compliance nuances: Visit edits require compliant reason codes and audit trails; data retention rules vary by jurisdiction
How Supergood Creates Optum APIs
Supergood reverse-engineers authenticated browser flows, batch interfaces, and network interactions to deliver a resilient API endpoint layer.
- Handles username/password, SSO/OAuth, and MFA (SMS, email, TOTP) securely
- Maintains session continuity with automated refresh and change detection
- Normalizes EVV, authorization, and claim objects so you can integrate once across programs
- Aligns with customer entitlements and licensing constraints to ensure compliant access
- Bridges batch exports and SFTP/EDI flows where applicable with signed URL retrieval and delivery
Getting Started
- Schedule Integration Assessment
Book a 30-minute session to confirm your Optum product mix, licensing, and authentication model.
- Supergood Builds and Validates Your API
We deliver a hardened Optum adapter tailored to your workflows and entitlements.
- Deploy with Monitoring
Go live with continuous monitoring and automatic adjustments as Optum evolves.
API Endpoints
Authentication
/sessionsEstablish a session using credentials. Supergood manages MFA (SMS, email, TOTP) and SSO/OAuth when enabled. Returns a short-lived auth token maintained by the platform.
Authorizations
/evv/authorizationsRetrieve payer/member service authorizations with allowed units, service codes, and validity dates. Use this to validate scheduling and claim eligibility, including Massachusetts (MassHealth) programs.
EVV Visits
/evv/visitsCreate or update an EVV visit record with check-in/out events, service details, and verification metadata. Supports compliant edit reason codes used for MassHealth reimbursement workflows.
Claims
/claimsAssemble an 837P/I claim from verified visits. Supergood normalizes service lines and can route the generated file to the configured submission channel (e.g., MassHealth portal, MCO gateway, or clearinghouse).
Use Cases
EHR-to-EVV Synchronization
- Push patient and provider rosters from your EHR into Optum-managed EVV programs - Create visits automatically from your scheduling system with correct service codes and modifiers - Maintain a single source of truth for demographics and eligibility
Authorization-Aware Scheduling and Eligibility
- Validate authorizations before scheduling or visit creation - Track remaining authorized units and prevent over-utilization - Surface program-specific rules to care coordinators
EVV Exception Resolution
- Pull exception queues and route issues (e.g., late arrival, missing check-out, GPS mismatch) to staff for resolution - Apply compliant reason codes on visit edits with audit trails - Escalate unresolved exceptions prior to claim submission
Claims Generation and Reimbursement Automation
- Bundle verified visits into 837P/I claims with payer-specific formatting - Submit via the configured channel (state portal, MCO gateway, or clearinghouse) - Track claim statuses and reconcile remittances alongside EVV evidence
Audit and Compliance
- Export complete visit packets with timestamps, locations, signatures, and reason codes - Maintain machine-readable audit trails aligned to program requirements - Prove EVV coverage and claim provenance during reviews
Technical Specifications
Authentication
Username/password with MFA (SMS, email, TOTP) and SSO/OAuth where enabled; supports service accounts or customer-managed credentials
Response format
JSON with consistent resource schemas and pagination
Rate limits
Tuned for enterprise throughput while honoring licensing and usage controls
Session management
Automatic reauth and cookie/session rotation with health checks
Data freshness
Near real-time retrieval of visits, authorizations, and claim artifacts
Security
Encrypted transport, scoped tokens, and audit logging; respects Optum entitlements and compliance requirements
Webhooks
Optional asynchronous delivery for exceptions, claim generation, and remittance updates
Latency
Sub-second responses for list/detail queries under normal load
Throughput
Designed for high-volume EVV and batch claims pipelines
Reliability
Retry logic, backoff, and idempotency keys minimize duplicate actions
Adaptation
Continuous monitoring for UI/API changes with rapid adapter updates
Frequently asked questions
Supergood supports workflows across commonly used Optum portals and payer-facing tools, subject to your licensing and entitlements. We scope coverage (e.g., EVV, authorizations, eligibility, visit exports, claim assembly, remittance retrieval) during integration assessment.
We support username/password + MFA (SMS, email, TOTP) and can operate behind SSO/OAuth when enabled. For batch flows, we manage SFTP/EDI timing windows, generate 837 files, and retrieve signed URLs or delivery confirmations programmatically.
Yes. You can assemble 837P/I from verified visits with payer-specific formatting and submit via your configured channel. We return statuses and artifacts for reconciliation alongside EVV evidence.