Health Cloud Administration

Administer Health Cloud
Where Do I Start with Health Cloud?
Health Cloud Data Models
Health Cloud Provider Network and Relationship Management
Health Cloud Sales and Commercial Excellence
Health Cloud Utilization Management
Health Cloud for Life Sciences
Health Cloud for Insurance
Types of People in Health Cloud
Quick Start List for a Successful Health Cloud Implementation
Set Up Health Cloud
Use the Health Cloud - Admin App
Customize the Health Cloud Console
Customize the Health Cloud Apps
Contact Center for Health Cloud
Code Sets and Code Set Bundles
Reporting in Health Cloud
Flow for Health Cloud
OmniStudio for Health Cloud
Help Patients Connect with Providers
Protect Personal Health Information
Experience Cloud Sites
Intelligent Appointment Management
Virtual Care
Medication Management and Medication Review
Advanced Therapy Management
Intelligent Document Automation
Intelligent Document Reader
Intelligent Form Reader
Document Generation in Health Cloud
Manage Patient or Member Care to Improve Outcomes
Integrated Care Management
Care Coordination for Slack
Unified Health Scoring
Home Health
Provide Easy Access to Protocols and Articles in Health Cloud
Provide Assessments and Surveys for Gathering Information and Feedback
Crisis Support Center Management
Manage Your Network of Providers
Behavioral Health App
Help High-Risk Patients and Members
Manage Care Requests
Authorization Requests
Utilization Management Setup Checklist
Authorization Request Process Setup for Payers
Set Up Care Request Configurations
Customize Case and Care Request Pages for Utilization Management
Enable the Utilization Management for Payers App
OmniStudio Components for the Payer Authorization Request Process
Configure Statuses for Authorization Requests
Configure Action Buttons for Processing Authorization Request Reviews
Manage Rules for Automating Authorization Request Workflows
Automate Workflows with Predefined Rules
Customize the Predefined Authorization Process
Set Up Peer-to-Peer Scheduling for Authorization Request Reviews
Create Custom Report Types and Custom Reports for Utilization Management
Experience Cloud Site for Utilization Management
Set Up Timeline Parameters for Tracking Authorization Reviews
Automate Case Routing with Omni-Channel
Authorization Request Process Setup for Providers
CRM Analytics for Utilization Management
Artificial Intelligence for Utilization Management
Verify Patient Benefits
Support Emergency Response Management and Contact Tracing
Use Care Programs to Track and Manage Cohorts of Patients and Members
Remote Monitoring Patients
Process Insurance Claims from External Sources
Automate Key User Tasks with Flows
Set up Action Plans
Manage Campaigns
Support and Manage Provider Referrals
CRM Analytics and Artificial Intelligence
Manage Commercial Excellence
Manage Inventories, Surgical Cases, and Cycle Counts with Intelligent Sales
Support Health Cloud for Mobile Users
Enhanced Timeline
Actionable Relationship Center in Health Cloud
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Automate Workflows with Predefined Rules

Simplify and expedite reviews of authorization requests by using built-in business rules and logic. Use the predefined expression set templates and define decision matrices to perform automatic validation, reduce administrative errors, and cut down on repetitive tasks.

Available in: Lightning Experience

Available in: Enterprise and Unlimited Editions with Health Cloud

User Permissions Needed
To define decision matrices and expression sets: RuleEngine Designer permission set

Utilization Management provides these prebuilt expression set templates that are readily integrated with the Omniscript processes:

  • HealthCloudUM_AutoApproval - Validates if an authorization request can be auto-approved without reviews
  • HealthCloudUM_DocsChecklist - Validates if an authorization request includes the required clinical documents
  • HealthCloudUM_NeedAssessment - Validates if the diagnostic and service codes requested in an authorization require approval

In tandem with these predefined expression set templates, you must define a set of decision matrices to obtain rule-based workflow automation.

  1. From the App Launcher, find and select Lookup Tables.
  2. Click New and select Decision Matrix.
  3. Use the following table to define the required decision matrices:
    1. Provide the name for the decision matrix.
    2. Set the Type as Standard.
    3. Add input and output columns for each decision matrix as specified.
      Decision Matrix Name Purpose Columns for Input Data Columns for Output Data
      HealthCloudUM_DocsChecklist Defines the list of mandatory documents required for a request type and region.
      • RequestType (Text)
      • Region (Text)
      		 Files (Text)

      Provide a comma-separated list of document names.

      Note
      NeedAssessmentRuleIndividualPlanConditions Indicates if authorization is required for a member who has an individual member plan.
      • ServiceCode (Text)
      • RequestType (Text)
      • PlanName (Text)
      • City (Text)
      • State (Text)
      		 Output (Text)
      • Required
      • Not Required
      NeedAssessmentRuleGroupPlanConditions Indicates if authorization is required for a member who has a group member plan.
      • ServiceCode (Text)
      • RequestType (Text)
      • PlanName (Text)
      • City (Text)
      • State (Text)
      		 Output (Text)
      • Required
      • Not Required
      HealthCloudUM_AutoApproval Indicates if authorization requests with a combination of specific input parameters can be automatically approved.
      • RequestType (Text)
      • ServicingProviderInNetwork (Boolean)
      • ServiceCode (Text)
      • IsMemberActive (Boolean)
      • MemberPlanLOB (Text)
      		 IsAutoApproved (Boolean)
  4. Add rows and values for each decision matrix, and save your changes.
  5. Edit the decision matrix version and set it to Enabled.
  6. Save your work.
  7. Next, from the App Launcher, find, and select Expression Set Templates.
  8. Clone each of these predefined expression set templates and save them as expression sets with the same name:
    • HealthCloudUM_AutoApproval
    • HealthCloudUM_DocsChecklist
    • HealthCloudUM_NeedAssessment
  9. Activate the expression set, set the rank as 1, and save your changes.

    Use the same name and input and output structure of the expression sets for accurate integration with the predefined OmniScripts.

    Important

Now, when your users create and review authorization requests, the guided workflow process refers to the predefined rules and validates the request details.