Deliver More Personalized and Appropriate Care with Utilization Management

Health Cloud streamlines utilization management processes so that healthcare providers and payers can collaborate seamlessly on case reviews. With utilization management, you can help provide consumers with the right care in the right place at the right time.

Where: The utilization management user interface is available only in Lightning Experience. You can set up and configure utilization management in either Lightning Experience or Salesforce Classic. This feature is available in orgs where Health Cloud is enabled.

When: Utilization Management features are made available through the new Health Cloud Platform permission set license. This permission set license is provisioned to all Health Cloud customers, based on their contracts, after the end of the Winter ’19 Production release upgrade. Once the Health Cloud Platform permission set license is provisioned to production orgs, you can replicate a new sandbox org and have access to Utilization Management.

Who: Users must have Health Cloud and the Health Cloud Platform permission set license assigned to them. Also, users need these permission sets: Health Cloud Permission Set License and Health Cloud Utilization Management.

Why: If your organization is a healthcare payer, such as an insurance company or health plan, processing and assigning requests is simpler and faster. It’s easier to gather patient and clinical data from the provider and coordinate the review of care requests from clinicians to medical directors.

For healthcare providers, utilization management makes it easy to submit care requests quickly with fewer phone calls and faxes for preauthorizations.

How: Health Cloud provides new standard objects to support a customizable set of requests:

  • Prescription drug preauthorization requests.
  • Service preauthorization requests
  • Admission cases
  • Concurrent (continued stay) reviews
  • Appeals
  • Complaints and grievances