Authorization Request Process Setup for Payers

Authorization requests require additional setup. A few configurations such as setting up an experience cloud site, timeline parameters, custom reports, and case routing are optional and are dependent on your organization's needs.

Before you proceed with this setup, complete Set Up Permissions and Data for Utilization Management.

• Authorization Request Process Flow in a Payer’s Office
  Utilization Management’s comprehensive approach for payers ensures that patients receive optimal medical care that’s delivered in the appropriate setting at the necessary time, while helping users properly manage high-cost care and hospitalizations.
• Enable the Utilization Management for Payers App
  Simplify authorization request reviews and provide your users with a comprehensive view of requests by enabling the Utilization Management for Payers App.
• Define Payer Statuses for Authorization Requests
  Care requests move through a series of steps from submission to approval. To get a clear understanding of the progress and assignment of requests, it’s critical to track the real-time status.
• Set Up Support Processes and Record Types for Payers
  In order to use Omniscript processes included in Omnistudio, configure support processes and record types that support Utilization Management. Assign profiles and page layouts to record types to determine which record types apply when users create, edit, or view records.
• Set Up Care Request Configurations
  Create care request configuration records for different types of care requests such as PreAuthorization, Admission, Drug Request or Service Request. Associate each configuration with a record type.
• Customize Case and Care Request Pages for Utilization Management
  Use the Lightning App Builder to design the Case and Care Request pages for users to handle care requests.
• Omnistudio Components for the Payer Authorization Request Process
  Utilization Management is built using a predefined suite of Omnistudio components, which combine to provide a smooth, guided user interaction that empowers users in your payer organization to easily handle the complex authorization process.
• Configure Action Buttons for Processing Authorization Request Reviews
  Help your users to launch Omniscripts and handle authorization requests in an efficient and timely manner by adding Flexcard-based action buttons to the Case record page or the Home page in the Utilization Management for Payers app. Conditionalize the visibility of the buttons based on the case status, case substatus, and request type.
• Manage Rules for Automating Authorization Request Workflows
  Use Business Rules Engine components and features to speed up and streamline approval processes, simplify complex lookups, and automate business decisions in your authorization request workflows.
• Customize the Predefined Authorization Process
  Provide additional flexibility for your users by customizing the predefined Omnistudio components and workflow rules. With these customizations, you can speed up process management and automation, and implement a simplified, time-saving solution to meet your organization's requirements.
• Set Up Peer-to-Peer Scheduling for Authorization Request Reviews
  Help your users to schedule and conduct timely peer-to-peer reviews with healthcare providers to discuss the actual or potential reason for denial of an authorization request.
• Create Custom Report Types and Custom Reports for Utilization Management
  Set up a custom report type and custom report so that your users can view and analyze data related to their authorization requests.
• Set Up Timeline Parameters for Tracking Authorization Reviews
  Define milestone trackers to give your users a complete view of upcoming and completed milestones, and display countdowns for active and overdue milestones. Your users can use these trackers to review authorization requests within specific timelines.
• Automate Case Routing with Omni-Channel
  Speed up and streamline the authorization approval process by automating workflows with routing configurations. Use Omni-Channel to quickly route cases to the correct users so that they can review authorization requests on time.
• Experience Cloud Site for Utilization Management
  Build and set up an Experience site to enable your site users handle authorization requests.
• Set Up Prior Authorization Request Deduplication
  Help your users manage prior authorization requests by maintaining clean and accurate data. To resolve prior authorization request case records, turn on Deduplication of Prior Authorization Requests in Setup. Unify your data across systems by enabling Data 360. Then, deploy the required data kits and configure the Identify and Resolve Duplicate Prior Authorization Requests flow. Finally, embed the flow on the case record page.
• Set Up Automatic Approval of Prior Authorization Requests
  To enable instant approval of qualifying prior authorization requests, turn on the Automatic Approval of Prior Authorization Requests setting. Then, clone and configure the Automatically Approve Prior Authorization Requests flow.