Health Cloud Administration

Administer Health Cloud
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Authorization Requests
Authorization Request Process Flow in a Provider’s Office
Authorization Request Process Flow in a Payer’s Office
Utilization Management Setup Checklist
Authorization Request Process Setup for Payers
Authorization Request Process Setup for Providers
CRM Analytics for Utilization Management
Artificial Intelligence for Utilization Management
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Authorization Requests

Medications, surgeries, personalized therapies, and healthcare treatments can all lead to huge bills for the payers and patients. Many of these expensive procedures can be avoided or replaced by simpler, cost-effective alternatives that take place in outpatient settings. To verify cost of care and medical necessity of procedures and treatments, payers must conduct authorization reviews of the care requests that providers raise.

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

But authorization reviews are often manual and highly dependent on variable factors such as care type and admission type, requiring users to switch between various processes to collate information. From need assessment to coverage benefit verification, authorization can be a lengthy process.

To ensure ease of access to information and smoother collaboration between payers and providers, Health Cloud’s Utilization Management provides these capabilities:

  • Centralized and guided workflows with multiple OmniStudio components that empower your users to easily manage authorization request submissions and reviews
  • Integrated payer app for seamless review processing
  • Automatic administrative checks based on rules
  • Controlled access based on request status
  • Context-specific notes for clinical documents, service codes, and others
  • Service-level agreement (SLA) tracking, along with analytics-based insights on SLA violations, during the review process
  • Custom reports to analyze care request data
  • Queue routing for streamlined approval process
  • FHIR R4 aligned data model for interoperability and integration with external systems

  • FHIR Da Vinci Health Record Exchange aligned APIs, deployed on MuleSoft, for uninterrupted request processing

    The Da Vinci Health Record Exchange (HRex) implementation guide (IG) is a foundational guide that defines FHIR profiles, operations, and guidance. HL7’s Da Vinci project produces standards and implementation guidelines based on HL7 FHIR to better connect payers and providers to tackle authorization requests.