OmniStudio Components for the Provider Authorization Request Process

Utilization Management provides a set of predefined OmniStudio Integration Procedures and DataRaptors to retrieve member information from the provider’s Electronic Health Record (EHR) system and to submit the authorization request to the payer’s system.

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

HealthCloudUtilizationManagementProviderAuthorizationRequest OmniScript

Let’s take a look at the different components used in the OmniScript that are used to retrieve information from the provider’s EHR system and submit the request to the payer system.

Name	Type	Details
HealthCloudUtilizationManagementProviderRetrievePatients	Integration Procedure	Retrieves patient records that match the given first name, last name, and date of birth from the provider’s EHR system. First name, last name, and date of birth are the mandatory input parameters.
HealthCloudUtilizationManagementProviderRetrievePatientsInputSetup	DataRaptor	Prepares and sets up the input data for retrieving patient records.
HealthCloudUtilizationManagementProviderRetrievePatientByPatientId	Integration Procedure	Retrieves the patient record that matches the given patient ID from the provider’s EHR system. Patient ID is a mandatory input parameter.
HealthCloudUtilizationManagementProviderRetrievePatientByPatientIdInputSetup	DataRaptor	Prepares and sets up the input data for retrieving the patient record matching the patient ID.
HealthCloudUtilizationManagementProviderRetrieveServiceRequests	Integration Procedure	Retrieves patient service requests that match the given patient ID, status, and type from the provider’s EHR system. Patient ID, status, and type are the mandatory input parameters.
HealthCloudUtilizationManagementProviderRetrieveServiceRequestsInputSetup	DataRaptor	Prepares and sets up the input data for retrieving the service requests.
HealthCloudUtilizationManagementProviderRetrieveInsuranceDetails	Integration Procedure	Retrieves patient insurance details that match the given patient ID from the provider’s EHR system. Patient ID is a mandatory input parameter.
HealthCloudUtilizationManagementProviderRetrieveInsuranceDetailsInputSetup	DataRaptor	Prepares and sets up the input data for retrieving the insurance details.
HealthCloudUtilizationManagementProviderRetrieveClinicalDetails	Integration Procedure	Retrieves patient clinical details that match the given patient ID and service requests from the provider’s EHR system. Patient ID is a mandatory input parameter.
HealthCloudUtilizationManagementProviderRetrieveClinicalDetailsInputSetup	DataRaptor	Prepares and sets up the input data for retrieving the clinical details.
HealthCloudUtilizationManagementProviderGenerateRequestId	Integration Procedure	Generates Request ID for a prior authorization request by appending timestamp to the logged in user's organization ID. This ID is required to make calls to the provider’s EHR system APIs.
HealthCloudUtilizationManagementProvider_GroupServiceRequests	Integration Procedure	Retrieves services requests of the patient based on the requesting provider.
HealthCloudUtilizationManagementProvider_SaveEHRAndClaimRecords	Integration Procedure	Saves the EHR data such as patient, provider, service requests in the Health Cloud Clinical data model and creates the corresponding authorization records in the Utilization Management data model.
HealthCloudUtilizationManagementProvider_MergeFinalResults	Integration Procedure	Prepare the data for the authorization request acknowledgment and summary using information from case, care request, account, and more.
HealthCloudUtilizationManagementProvider_InitiateEPA	Integration Procedure	Uses caseId, requestGuid, and claimBundleInputs information to invoke a remote call for submitting authorization request to payer. Also, the integration procedure saves the response received from payer in the Utilization Management data model.
HealthCloudUtilizationManagementProviderCheckPreAuthRecordType	DataRaptor	Verifies whether the preauthorization record type is available for all the required Utilization Management objects and retrieves the corresponding Salesforce IDs.
HCUMProviderUpdateContentDocumentName	DataRaptor	Updates the content document associated with an authorization request.
HCUMProviderAttachContentDocumentToCase	DataRaptor	Attaches the content document to the case record for an authorization request.
HCUMProvider_OperationOutcome	Integration Procedure	Updates a single error string in OperationOutcomeError properties based on the error messages received from OperationOutcome MuleSoft API response.
HealthCloudUtilizationManagementGetCaseDetails	DataRaptor	Retrieves the case details associated with the authorization request.
HealthCloudUtilizationManagementProviderGetPatientAccountDetails	DataRaptor	Retrieves the patient details associated with the authorization request.
HealthCloudUtilizationManagementProviderPatientHeader	FlexCard	Displays a list of patient records matching the patient search criteria.
HealthCloudUtilizationManagementProviderEmptyState	FlexCard	Displays an empty state image and message when no patients are found.
HealthCloudUtilizationManagementProviderServiceRequests	FlexCard	Displays the list of service requests associated with the patient and requesting provider.
HealthCloudUtilizationManagementProviderSelectedPatientDetails	FlexCard	Displays basic information of the patient for whom the authorization request is submitted.
HealthCloudUtilizationManagementProviderRequestingProviderDetails	FlexCard	Displays details of the requesting provider associated with a service request.
HealthCloudUtilizationManagementProviderClinicalDetails	FlexCard	Displays clinical encounter and diagnosed condition details of a selected patient and service request.
HealthCloudUtilizationManagementProviderMemberPlanDetails	FlexCard	Displays member plan details of a selected patient.
HealthCloudUtilizationManagementProviderAcknowledgment	FlexCard	Displays an acknowledgment message for the authorization request submission.
HealthCloudUtilizationManagementProviderSubmissionFailedEmptyState	FlexCard	Displays an empty state image and message when the authorization request isn’t submitted.
HealthCloudUtilizationManagementProviderCreatePriorAuthRequest	Integration Procedure	Creates a prior authorization request and records based on inputs retrieved from the provider’s EHR system. The ID of the care request item is updated in serviceRequestsResponses of the preClaimSubmitInfo parameter.
HealthCloudUtilizationManagementProviderRetrieveRecordIdByCode	DataRaptor	Retrieves the record ID from the provider system that matches the code received from the EHR system.
HealthCloudUtilizationManagementProviderCreatePriorAuthRequest	DataRaptor	Creates a prior authorization request based on inputs retrieved from the provider’s EHR system.
HealthCloudUtilizationManagementProviderPriorAuthCreationSetup	DataRaptor	Sets up the recordTypeId, careRequest, and claimBundleInputs details for creating a prior authorization request.
HealthCloudUtilizationManagementProviderSubmitPriorAuthRequest	Integration Procedure	Submits the prior authorization request to the payer system.
HealthCloudUtilizationManagementProviderPriorAuthSubmissionSetup	DataRaptor	Sets up the prior authorization request details for submission to the payer.
HealthCloudUtilizationManagementProviderSavePriorAuthResponse	Integration Procedure	Saves the response that’s received on the prior authorization request from the payer system.
HealthCloudUtilizationManagementProviderUpdatePriorAuthResponse	DataRaptor	Updates the prior authorization request with the response that’s received from the payer system.

HealthCloudUtilizationManagementProviderInquiryRequest OmniScript

Let’s take a look at the different components used in the OmniScript that are used to manage the authorization request inquiry process to get the latest status of a request.

Name	Type	Details
HCUMInquiryFetchClaimDetails	DataRaptor	Retrieves information related to the case, care request, care request extension, and care request item records based on the Case ID.
HCUMInquiryPatientDetails	DataRaptor	Retrieves details related to the patient account and identifier records based on the Patient ID.
HCUMInquiryProviderDetails	DataRaptor	Retrieves the HealthCareProvider, HealthCareProviderNPI, and Identifier records record based on the Provider ID.
HCUMInquiryInsuranceDetails	DataRaptor	Retrieves details of the member plan based on Member Plan ID.
HCUMInquiryFetchPayorDetails	DataRaptor	Retrieves details of the payer based on payer ID.
HCUMProvider_FetchInquiryBundle	Integration Procedure	Sets up the inquiry resource bundle for submitting an inquiry request on a case.
HCUMProvider_SubmitInquiry	Integration Procedure	Uses the inquiry resource bundle and request ID as input to invoke an APEX remote action that performs an HTTP request callout to the payer. Also, this integration procedure returns claimResponse as output.
HCUMProvider_OperationOutcome	Integration Procedure	Updates a single error string in OperationOutcomeError properties based on the error messages received from OperationOutcome MuleSoft API response.
HealthCloudUtilizationManagementProvider_GenerateRequestId	Integration Procedure	Generates Request ID for a prior authorization request by appending timestamp to the logged in user's organization ID. This ID is required to make calls to the provider’s EHR system APIs.
HealthCloudUtilizationManagementProvider_SavePriorAuthResponse	Integration Procedure	Saves the response that’s received on the prior authorization request from the payer system.
HealthCloudUtilizationManagementProviderUpdatePriorAuthResponse	DataRaptor	Updates the prior authorization request with the response that’s received from the payer system.
HealthCloudUtilizationManagementProvider_MergeFinalResults	Integration Procedure	Prepare the data for the authorization request summary using information from case, care request, account, and more.
HealthCloudUtilizationManagementGetCaseDetails	DataRaptor	Retrieves the case details associated with the authorization request.
HealthCloudUtilizationManagementProviderGetPatientAccountDetails	DataRaptor	Retrieves the patient details associated with the authorization request.
HealthCloudUtilizationManagementProviderSelectedPatientDetails	FlexCard	Displays basic information of the patient for whom the authorization request is submitted.
HealthCloudUtilizationManagementProviderAcknowledgment	FlexCard	Displays an acknowledgment message for the authorization request submission.
HealthCloudUtilizationManagementProviderSubmissionFailedEmptyState	FlexCard	Displays an empty state image and message when the authorization request isn’t submitted.
HealthCloudUtilizationManagementProviderInquiryLaunch	FlexCard	Starts the authorization request inquiry process.
HealthCloudUtilizationManagementProviderInquiryRequestModal	FlexCard	Displays case summary and submits the inquiry request to the payer.

We recommend using cloned versions of these OmniScripts and FlexCards so that you don’t face any process disruptions when predefined OmniScripts are updated during automatic upgrades. Simply clone each OmniScript and FlexCard, retain the settings, save with a different name, and activate the cloned version. Relink each cloned FlexCard to the corresponding cloned OmniScript.

Note

Health Cloud Administration

OmniStudio Components for the Provider Authorization Request Process