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            Set Up Permissions and Data for Utilization Management

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            Set Up Permissions and Data for Utilization Management

            To use Utilization Management, complete these prerequisites.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            • Complete the basic setup for Health Cloud.
            • Ensure system admins have these permission sets and permission set licenses:
              • Health Cloud Platform permission set license, which includes the Health Cloud Foundation and Health Cloud Utilization Management permission sets
              • Omnistudio Admin permission set, which also includes the permissions granted by the Omnistudio User permission set
              • RuleEngine Designer permission set, which also includes the permissions granted by the RuleEngine Runtime permission set
            • Assign these permission sets to your users:
              • Health Cloud Foundation
              • Health Cloud Utilization Management
              • Omnistudio User permission set
              • RuleEngine Runtime permission set
            • For payers, ensure you have the MuleSoft - Salesforce Healthcare APIs SKU to use the payer inbound API: Prior Authorization API
            • For providers:
              • Enable the Health Cloud: Utilization Management for providers org permission.
              • Enable the IndustriesServiceExcellence add on license or the IndustriesServiceExcellence platform license.
              • Enable the FHIR-aligned Clinical Data Model.
              • Ensure you have the MulesSoft add-on product called MuleSoft Direct for Health cloud to use the provider APIs: Prior Authorization EMR Retrieval API and Prior Authorization Claim Submission API
            • Ensure your org data is set up using these objects:
              ObjectType of Data
              Account (business accounts and person accounts) Member and provider details
              Purchaser Plan and Member PlanMember’s insurance plan details
              Healthcare Payer Network (business account)Payer details
              Healthcare Provider (business accounts and person accounts), Healthcare Provider NPI, Board Certification, Healthcare Provider Taxonomy, ContactRequesting and servicing provider details
              Healthcare Facility (for business accounts) and Healthcare Practitioner Facility (for person account’s contact)Payer and provider facility details
              Code SetsService code, diagnosis code, and care processing error code details. These are industry-standard ICD-10 codes.
            • Add care request type values to the Type field picklist on the Case object. For example, Initial Request, Extension or Amendment.
             
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