Help ensure eligibility and benefits information is accurate
Drive claim accuracy with a network that includes more than 2,400 payer connections.
Our broad connectivity facilitates the exchange of up-to-date information to drive time and cost efficiencies and help support accurate, accelerated reimbursement. We offer multiple options to improve the submission, processing and tracking of claims and attachments.
Our productized APIs are easy to implement and scale, giving you fast access to functionality spanning:
- Patient and member engagement
- Eligibility and claims processing
- Data and interoperability management
Explore our Medical Network Solutions
Software
EDI Network
Leverage our vast nationwide payer network to enable swift and secure sharing of information between providers, payers and patients.
Software
Smart EDI
Our advanced transaction management and routing services help you manage complex EDI workflows and reduce costly denials.
Service
Optum AI Marketplace
Your destination for healthcare innovation. Explore, test and purchase software APIs and services designed to solve real challenges and improve outcomes. Connect with trusted partners and discover solutions that turn breakthrough technology into meaningful impact.
Software
Hosted Payer Services
Reduce payer administrative costs and remove technical barriers by providing real-time eligibility and claim status services on behalf of payer customers.
API-first revenue cycle integration
Available through the Optum AI Marketplace, these RESTful APIs support real-time, near real-time and batch transactions for eligibility, claims, attachments, prior authorization and remittance.
They use JSON to simplify EDI workflows, integrate with practice management systems or custom applications and connect to most U.S. payers.
A sandbox environment is available for testing functionality without the need for legacy infrastructure.
Medical Network Solutions FAQ
Our medical network connects to a broad payer network and uses HIPAA‑standard transactions to deliver real‑time, accurate eligibility and benefits data. This can help:
- Cut errors at registration.
- Support cleaner claims.
- Speedup reimbursement
To catch issues before submission, claim denials are reduced through:
- Advanced routing
- Automated edits
- Real‑time validation
With cleaner data upfront, payers see fewer resubmits, higher first‑pass rates and smoother reimbursement cycles.
APIs add agility, powering real‑time eligibility checks, claim status, prior auth and digital attachments. APIs also:
- Simplify integration with core systems.
- Reduce manual touchpoints.
- Deliver faster, more reliable results
Payer networks often include thousands of endpoints, which expand access to current member data and preferred claim routes.
This matters because it reduces delays, improves accuracy and makes workflows more resilient during spikes or system changes.
Automation trims manual work across eligibility, claims and status. Faster, cleaner transactions reduce rework and call volume, lowering operating costs so teams can focus on higher‑value work.
Network services align to HIPAA standards and operating rules, enabling secure, compliant exchange of protected health information (PHI). Consistent adherence strengthens audit readiness and lowers the risk of fines or remediation.
Connectivity and integrated analytics can:
- Improve provider data quality
- Support credentialing
- Surface gaps in network adequacy
This can help keep directories accurate and help members reach the right care faster.
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