Utilization Management is a critical component in healthcare that focuses on ensuring the
appropriateness, necessity, and efficiency of healthcare services. For payers working with plan
members and medical providers, the case-by-case review of care appropriateness requires thorough
processes to streamline authorization and review tasks.
Designing Care Requests to Seek Authorization (Answer B):
Purpose: The Care Request object in Health Cloud is essential for seeking authorizations from a
health plan for specific healthcare services, drugs, or admissions. This object ensures that requests
are appropriately documented and tracked.
Functionality:
It allows users to create and manage care requests linked to plan members.
Integrates with payer systems to capture critical details for authorization, such as service codes, plan
information, and medical necessity documentation.
Supports automation through workflows and approvals, speeding up the decision-making process.
Relevance: By designing efficient Care Requests, the consultant ensures that all required details for
preauthorizations or service reviews are captured seamlessly, meeting regulatory and operational
needs.
Considering Request Review Types (Answer C):
Purpose: UM processes in Health Cloud must address the three primary types of reviews:
Prior Authorization Review: Conducted before the service is provided to determine medical
necessity.
Concurrent Review: Evaluates the necessity of ongoing care during hospitalization or service delivery.
Retrospective Review: Analyzes the appropriateness of care after it has been delivered.
Implementation in Health Cloud:
The consultant must design workflows and data models to capture the details of these review types,
including timestamps, reviewer notes, and outcomes.
Health Cloud supports tracking and documenting these reviews within the UM module, ensuring
compliance with healthcare regulations.
Relevance: These review types allow the payer to influence decisions by ensuring appropriate care is
provided while managing costs and maintaining high-quality outcomes.
Why the Other Options Are Less Relevant:
A . Designing Next Best Action and Recommendations for the Care Management Team: While
recommendations and next-best-action features are beneficial for care management, they are not
directly tied to the case-by-case review process of Utilization Management, which focuses more on
care appropriateness and authorizations.
D . Considering the Number of Intake Agents Using Health Cloud: While operational considerations
like staffing are important, this is not a Utilization Management process. It's a broader organizational
concern unrelated to the core functionality of UM in Health Cloud.
Reference:
Utilization Management Overview: Salesforce documentation outlines how to handle prior
authorizations, service approvals, and related processes within Health Cloud. (help.salesforce.com)
Care Requests and Authorizations: Details on managing care requests and integrating with payer
systems for streamlined authorization workflows. (developer.salesforce.com)
UM Process Design in Health Cloud: Guidance on implementing request review types and managing
data models to support UM. (architect.salesforce.com)
By addressing Care Requests and Request Review Types, the consultant ensures a robust Utilization
Management setup, enabling effective collaboration between payers, providers, and members while
optimizing care delivery and compliance.
