Access External Insurance Claims Data

The claims data model uses the power of Salesforce Lightning Connect to make externally sourced insurance claims data available in Health Cloud. Give your users access to claims information so that they can quickly and efficiently answer queries from providers and members without using multiple screens or applications.

Where: This feature is available in Lightning Experience, Salesforce Classic, and all versions of the Salesforce app in Professional, Performance, and Unlimited editions where Health Cloud is enabled. In addition, you must also have Salesforce Lightning Connect licensed in your org.

When: The claims data model is available through an unmanaged package after the Winter ’19 Production release upgrade.

Who: Users must have Health Cloud and the Health Cloud Platform permission set license assigned to them. Users also need these permission sets: Health Cloud Permission Set License and Health Cloud Member Services.

Why: Whether you’re dealing with member services or care management, you want your users to have instant access to information that they need. The claims data model represents important data from your external claims processing system that you can make available to call center agents and other users.

The claims data model includes these external objects.
  • Claim Header—Represents summary information about the claim, such as the payment amount, specified medications, claim date, and insurance plan.
  • Claim Line—Represents a line item in a claim record.
  • Claim Diagnosis—Represents the clinical diagnosis for which the service, equipment, or medication was provided.
  • Claim Diagnosis Procedure—Represents a diagnosis associated with a clinical procedure in a claim line.
  • Claim Provider—Represents information about the different providers on the claim, such as the billing provider or the rendering provider.

How: You must have the Health Cloud managed package installed in your org to enable the Health Cloud claims data model. In Lightning Experience, from Setup, enter External Objects in the Quick Find box, then select External Objects.