Authorization Request Process Setup for Payers | Health Cloud Administration

Help your payer users to easily handle and review authorization requests with a predefined app and set of OmniScripts. These components present a centralized view of the information needed for prior authorization and concurrent reviews, from eligibility check, to uploading supporting documents, to final approval.

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

Authorization requests require some additional setup. Few configurations such as setting up an experience cloud site, timeline parameters, custom reports, and case routing are optional and are dependent on your business needs.

Before you proceed with this process: Set Up Permissions and Data for Utilization Management

Set Up Care Request Configurations
Create care request configuration records for different types of care requests such as Prescription drugs, Admission, PreAuthorization, or Service.
Customize Case and Care Request Pages for Utilization Management
Use the Lightning App Builder to design the Case and Care Request lightning pages for users to handle care requests.
Enable the Utilization Management for Payers App
Simplify authorization request reviews and provide your users with a comprehensive view of requests by enabling the Utilization Management for Payers App.
OmniStudio Components for the Payer Authorization Request Process
Utilization Management is built using a predefined suite of OmniStudio components, which combine to provide a smooth, guided user interaction that empowers your payer users to easily handle the complex authorization process.
Configure Statuses for Authorization Requests
Care requests move through a series of steps from submission to approval. To get a clear understanding of the progress and assignment of requests, it’s critical to track the real-time status.
Configure Action Buttons for Processing Authorization Request Reviews
Help your users to launch OmniScripts and handle authorization requests in an efficient and timely manner by adding FlexCard-based action buttons to the Case record page. Visibility of the buttons is based on the case status, case substatus, and request type.
Manage Rules for Automating Authorization Request Workflows
Use Business Rules Engine components and features to speed up and streamline approval processes, simplify complex lookups, and automate business decisions in your authorization request workflows.
Customize the Predefined Authorization Process
Keep pace with ever-changing business needs and provide additional flexibility for your users by customizing the predefined OmniStudio components and workflow rules. With these customizations, you can speed up process management and automation, and implement a simplified, time-saving solution to meet your business needs.
Set Up Peer-to-Peer Scheduling for Authorization Request Reviews
Help your users to schedule and conduct timely peer-to-peer reviews with healthcare providers to discuss the actual or potential reason for denial of an authorization request.
Create Custom Report Types and Custom Reports for Utilization Management
Set up a custom report type and custom report so that your users can view and analyze data related to their authorization requests.
Experience Cloud Site for Utilization Management
Build and set up an Experience site to enable your site users handle authorization requests.
Set Up Timeline Parameters for Tracking Authorization Reviews
Define milestone trackers to give your users a complete view of upcoming and completed milestones, and display countdowns for active and overdue milestones. Your users can use these trackers to review authorization requests within specific timelines.
Automate Case Routing with Omni-Channel
Speed up and streamline the authorization approval process by automating workflows with routing configurations. Use Omni-Channel to quickly route cases to the correct users so that they can review authorization requests on time.