# Optum Claims & Billing MCP

> Optum Claims & Billing MCP connects your AI agent directly to Optum's financial APIs. Submit professional and institutional medical bills, track their status immediately, download detailed payment remittances, and automatically resubmit corrections for denied claims. This tool handles the entire revenue cycle back-office process.

## Overview
- **Category:** industry-titans
- **Price:** Free
- **Tags:** medical-billing, edi, claims-processing, remittance, healthcare-compliance

## Description

Processing medical payments shouldn't involve mountains of paper or endless manual reconciliation. This MCP gives your AI client direct access to Optum’s core APIs, letting you take control of your billing lifecycle. You can construct and send complex claims—whether it's a doctor's office visit (professional) or a major hospital stay (institutional). Need to know if that claim went through? Check the status instantly to see if it's approved, pending review, or rejected. When payments land in the bank, you don’t have to manually download statements; this MCP pulls down structured Electronic Remittance Advice records for easy reconciliation. If a payer denies a bill due to coding errors, you can even use the agent to fix and resubmit the corrected claim automatically. Vinkius hosts this critical connector so your AI client can manage all these complex financial actions without needing specialized software or manual intervention.

## Tools

### opt_check_claim_status
Checks the current status of a medical bill, telling you if it's pending, denied, or paid.

### opt_get_remittance_advice
Downloads payment records (ERA 835) that detail exactly how much money was received and for which services.

### opt_handle_denial_revision
Fixes coding errors on a rejected claim and resubmits the corrected version to overturn the denial.

### opt_submit_institutional_claim
Submits large medical bills (837I) associated with hospital stays or major facility services.

### opt_submit_professional_claim
Sends professional medical claims (837P) for outpatient visits and services provided by doctors.

## Prompt Examples

**Prompt:** 
```
Check the status of the institutional claim ID 88829281X.
```

**Response:** 
```
Query completed. The medical claim 88829281X is currently Approved and expects a check date on May 15.
```

**Prompt:** 
```
List the latest ERA remittances available for clearing.
```

**Response:** 
```
Pulled 3 recent ERA 835s from UnitedHealth Group clearinghouse totaling $12,450.00 ready for auto-posting.
```

**Prompt:** 
```
Draft an 837 payload for an office visit code 99213.
```

**Response:** 
```
The ANSI 837 Professional Claim string has been successfully prepared for code 99213 passing all pre-adjudication compliance checks.
```

## Capabilities

### Submit Medical Bills
Send professional (outpatient) and institutional (hospital stay) medical claims directly to the payer for payment processing.

### Track Claim Status
Check the real-time status of any submitted claim, knowing immediately if it's approved, denied, or still under review.

### Download Payment Records
Retrieve detailed Electronic Remittance Advice (ERA 835) files that break down exactly how much money was paid and why.

### Correct and Resubmit Claims
Automatically fix coding or administrative errors on a rejected claim and resend the corrected version to overturn the denial.

## Use Cases

### Reconciling a large payment batch
A Billing Analyst needs to know what payments arrived last week. They ask their agent to use opt_get_remittance_advice, and the MCP pulls three detailed ERA 835 files, showing every dollar amount and which specific services they cover.

### Following up on a denied claim
A Billing Manager finds out that a hospital stay was billed incorrectly. They instruct their agent to use opt_handle_denial_revision, fixing the coding errors in minutes and resubmitting the corrected 837I payload.

### Submitting routine doctor visits
An office administrator needs to process fifty daily appointments. They ask their agent to use opt_submit_professional_claim, batch-submitting all the necessary professional bills (837P) in one secure operation.

### Verifying pending claim status
A user needs to know if a major surgical bill is approved. They query their agent using opt_check_claim_status and get an immediate response: 'Approved, check date May 15th.'

## Benefits

- Stop manually chasing payments. You can use opt_get_remittance_advice to pull detailed ERA 835 records instantly, giving you a complete financial picture of every incoming check.
- Speed up the entire billing cycle. Instead of waiting for human review, your agent submits claims using opt_submit_professional_claim or opt_submit_institutional_claim and tracks them with opt_check_claim_status.
- Eliminate denial bottlenecks. When a claim gets rejected due to coding errors, you don't have to start over. You just use opt_handle_denial_revision to fix the issue and resubmit it right away.
- Gain comprehensive oversight. Your AI client can manage both the initial submission of bills and the final reconciliation of funds in one workflow, linking payments directly back to submitted claims.
- Maintain compliance and security. This MCP is built specifically for hospital back-office finance, isolating billing data from general patient records.

## How It Works

The bottom line is that you get automated access to Optum’s entire claims processing workflow without ever touching a manual form or waiting on batch file uploads.

1. First, you insert your financial client ID into the runtime module. This securely authorizes your agent's ability to send or receive sensitive billing data.
2. Next, you tell your AI client what needs doing—for example, submitting an institutional claim or fetching recent remittance advice.
3. The MCP executes the API call, returns a structured result (like the final status code or a payment payload), and feeds it back to your agent for action.

## Frequently Asked Questions

**Does Optum Claims & Billing help with both hospital and office visits?**
Yes, it handles both major facility payments (institutional) using opt_submit_institutional_claim and smaller doctor/outpatient services (professional) via opt_submit_professional_claim.

**How can I check the status of a bill submitted through Optum Claims & Billing?**
You use the opt_check_claim_status tool. This gives you an immediate, definitive answer on whether your medical claim is approved, denied, or still pending review.

**What kind of data does opt_get_remittance_advice provide?**
This tool downloads the ERA 835. It provides a detailed breakdown of payments, showing exactly which payer paid how much and for what specific services rendered.

**Is this MCP secure enough for handling financial data?**
Yes. The architecture is engineered specifically to handle back-office finances, ensuring high security and compliance by keeping billing functions separate from general patient records.

**Can I use Optum Claims & Billing to fix a rejected claim?**
Absolutely. You use opt_handle_denial_revision. This process allows you to correct coding errors and resubmit the necessary documentation to overturn a payer denial.