Set Up Artificial Intelligence Use Cases

Get predictions about the likelihood of prior authorization requests breaching service-level agreements (SLA), and recommendations about services that are likely to be received and requested by payers and providers.

• Assign Permission Sets for the CRM Analytics Templates
  Assign permission sets to Salesforce admins and users based on their required level of access to the Prior-Authorization Review SLA Breach Predictions and Services Pathway and Bundling Recommendations CRM Analytics templates.
• Configure Field-Level Security for Analytics Integration Users
  Provide Analytics Cloud integration users required access to the fields used by the apps created by using the Prior-Authorization Review SLA Breach Likelihood template or the Services Pathway and Bundling Recommendations template.
• Set Up Your Salesforce Org to Use the Templates
  Set up Utilization Management before using the Prior-Authorization Review SLA Breach Likelihood template or the Services Pathway and Bundling Recommendations template.
• Prior-Authorization Review SLA Breach Predictions
  Get predictions about the likelihood of prior authorization requests breaching service-level agreements (SLA) by creating an app using the Prior-Authorization Review SLA Breach Likelihood template. Payers can use these predictions to review top factors that cause delays and ensure SLA-compliance by acting on them.
• Services Pathway and Bundling Recommendations
  Get recommendations about the services that are likely to be received by payers based on a member’s primary diagnosis by creating an app using the Services Pathway and Bundling Recommendations template. You also get recommendations about the services that are likely to be requested by providers based on a member’s primary diagnosis and previously submitted authorization requests. Use these recommendations to make quicker clinical determinations and provide timely care.
• Care Professional Recommendations by Using Scoring Framework
  Use Scoring Framework to get the top three recommended care professionals for patients based on care professionals’ missed appointment history, treatment frequency for multiple parameters, utilization rates, and average service appointment duration. Use this information to identify care professionals who are best suited for patient needs, and avoid last-minute rescheduling. Maximize patient satisfaction by assigning available care professionals with high effectiveness scores, and avoid discontentment among care professionals by distributing work equitably.
• Use Artificial Intelligence
  Payers can see the predicted service-level agreement (SLA) breach scores for prior authorization review requests and the top factors that possibly contribute to SLA breaches on the Prior-Authorization Review SLA Breach Prediction dashboard. They can see services that they are likely to receive from providers and previously submitted services authorization requests for a member on the Recommended Services Pathway dashboard. Providers can see services that they are likely to request on the Recommended Services Bundling dashboard.