Add Code Sets to Pre-Authorization Requests and Approval Processes

When a provider submits an authorization request, it must include codes for what is being requested and why. Similarly, payers must respond with what is being approved by using industry-standard code sets. Give service agents, provider staff, and others involved in prior-authorization requests access to industry-standard procedure or diagnosis codes.

Where: This feature is available through the Health Cloud Platform permission set license in Lightning Experience and Salesforce Classic in Enterprise, Performance, and Unlimited editions where Health Cloud is enabled.

When: Social Determinants and Code Sets data model features are provisioned to all Health Cloud customers, based on their contracts, after the end of the Spring '19 release upgrade. Once the features are available in production orgs, you can replicate a new sandbox org and have access to Social Determinants and the Code Sets data model.

Who: Users must have Health Cloud and the Health Cloud Platform permission set license assigned to them. Users also need at least one of the following permission sets: Health Cloud Permission Set License, Health Cloud Utilization Management, or Health Cloud Member Services.

Why: With the new code sets data model, you can make industry-standard procedure and diagnosis codes available to use in Health Cloud. These codes can be used to store discrete procedures and diagnoses as part of a patient's clinical record, or be used in pre-authorization requests in utilization management.

How: Acquire codes, such as the Current Procedural Terminology (CPT) or the International Statistical Classification of Diseases and Related Health Problems (ICD), from the American Medical Association or similar organizations. Use Data Loader to import the codes, and then map diagnosis code fields to the HealthCareDiagnosis object, and map the procedure codes to the HealthCareProcedure object. You can modify the data that’s displayed so that only the information your company uses is visible. Use sharing rules to grant access to the individuals who work with code sets.