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            Omnistudio Components for the Provider Authorization Request Process

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            Omnistudio Components for the Provider Authorization Request Process

            Utilization Management provides a set of predefined Omnistudio Integration Procedures and Omnistudio Data Mappers to retrieve member information from the provider’s Electronic Health Record (EHR) system and to submit the authorization request to the payer’s system.

            Required Editions

            Available in: Lightning Experience

            Available in: Enterprise and Unlimited Editions with Health Cloud
            Note
            Note The predefined Omnistudio components represent a default implementation and are ready to use. However, we recommend you customize these components per your organization's requirements. To do so, save a new version of each Omniscript and clone the associated Data Mappers and Integration Procedures. Retain the settings, save the new version or clone with a different name, activate the new version or the clone, and then relink the components. Similarly, clone and activate the Flexcards that launch these Omniscripts and relink them to the corresponding new versions of the Omniscripts. Cloning ensures that you don’t face any process disruptions when predefined components are updated during automatic upgrades.

            HealthCloudUtilizationManagementProviderAuthorizationRequest Omniscript

            Let’s see how this Omniscript's components retrieve information from the provider’s EHR system and submit the request to the payer system.

            Name Type Details
            HealthCloudUtilizationManagementProviderRetrievePatients Integration Procedure Retrieves patient records that match the given first name, last name, and date of birth from the provider’s EHR system. First name, last name, and date of birth are the mandatory input parameters.
            HealthCloudUtilizationManagementProviderRetrievePatientsInputSetup Data Mapper Prepares and sets up the input data for retrieving patient records.
            HealthCloudUtilizationManagementProviderRetrievePatientByPatientId Integration Procedure Retrieves the patient record that matches the given patient ID from the provider’s EHR system. Patient ID is a mandatory input parameter.
            HealthCloudUtilizationManagementProviderRetrievePatientByPatientIdInputSetup Data Mapper Prepares and sets up the input data for retrieving the patient record matching the patient ID.
            HealthCloudUtilizationManagementProviderRetrieveServiceRequests Integration Procedure Retrieves patient service requests that match the given patient ID, status, and type from the provider’s EHR system. Patient ID, status, and type are the mandatory input parameters.
            HealthCloudUtilizationManagementProviderRetrieveServiceRequestsInputSetup Data Mapper Prepares and sets up the input data for retrieving the service requests.
            HealthCloudUtilizationManagementProviderRetrieveInsuranceDetails Integration Procedure Retrieves patient insurance details that match the given patient ID from the provider’s EHR system. Patient ID is a mandatory input parameter.
            HealthCloudUtilizationManagementProviderRetrieveInsuranceDetailsInputSetup Data Mapper Prepares and sets up the input data for retrieving the insurance details.
            HealthCloudUtilizationManagementProviderRetrieveClinicalDetails Integration Procedure Retrieves patient clinical details that match the given patient ID and service requests from the provider’s EHR system. Patient ID is a mandatory input parameter.
            HealthCloudUtilizationManagementProviderRetrieveClinicalDetailsInputSetup Data Mapper Prepares and sets up the input data for retrieving the clinical details.
            HealthCloudUtilizationManagementProviderGenerateRequestId Integration Procedure Generates Request ID for a prior authorization request by appending timestamp to the logged in user's organization ID. This ID is required to make calls to the provider’s EHR system APIs.
            HealthCloudUtilizationManagementProvider_GroupServiceRequests Integration Procedure Retrieves services requests of the patient based on the requesting provider.
            HealthCloudUtilizationManagementProvider_SaveEHRAndClaimRecords Integration Procedure Saves the EHR data such as patient, provider, service requests in the Health Cloud Clinical data model and creates the corresponding authorization records in the Utilization Management data model.
            HealthCloudUtilizationManagementProvider_MergeFinalResults Integration Procedure Prepare the data for the authorization request acknowledgment and summary using information from case, care request, account, and more.
            HealthCloudUtilizationManagementProvider_InitiateEPA Integration Procedure Uses caseId, requestGuid, and claimBundleInputs information to invoke a remote call for submitting authorization request to payer. Also, the integration procedure saves the response received from payer in the Utilization Management data model.
            HealthCloudUtilizationManagementProviderCheckPreAuthRecordType Data Mapper Verifies whether the preauthorization record type is available for all the required Utilization Management objects and retrieves the corresponding Salesforce IDs.
            HCUMProviderUpdateContentDocumentName Data Mapper Updates the content document associated with an authorization request.
            HCUMProviderAttachContentDocumentToCase Data Mapper Attaches the content document to the case record for an authorization request.
            HCUMProvider_OperationOutcome Integration Procedure Updates a single error string in OperationOutcomeError properties based on the error messages received from OperationOutcome MuleSoft API response.
            HealthCloudUtilizationManagementGetCaseDetails Data Mapper Retrieves the case details associated with the authorization request.
            HealthCloudUtilizationManagementProviderGetPatientAccountDetails Data Mapper Retrieves the patient details associated with the authorization request.
            HealthCloudUtilizationManagementProviderPatientHeader Flexcard Displays a list of patient records matching the patient search criteria.
            HealthCloudUtilizationManagementProviderEmptyState Flexcard Displays an empty state image and message when no patients are found.
            HealthCloudUtilizationManagementProviderServiceRequests Flexcard Displays the list of service requests associated with the patient and requesting provider.
            HealthCloudUtilizationManagementProviderSelectedPatientDetails Flexcard Displays basic information of the patient for whom the authorization request is submitted.
            HealthCloudUtilizationManagementProviderRequestingProviderDetails Flexcard Displays details of the requesting provider associated with a service request.
            HealthCloudUtilizationManagementProviderClinicalDetails Flexcard Displays clinical encounter and diagnosed condition details of a selected patient and service request.
            HealthCloudUtilizationManagementProviderMemberPlanDetails Flexcard Displays member plan details of a selected patient.
            HealthCloudUtilizationManagementProviderAcknowledgment Flexcard Displays an acknowledgment message for the authorization request submission.
            HealthCloudUtilizationManagementProviderSubmissionFailedEmptyState Flexcard Displays an empty state image and message when the authorization request isn’t submitted.
            HealthCloudUtilizationManagementProviderCreatePriorAuthRequest Integration Procedure Creates a prior authorization request and records based on inputs retrieved from the provider’s EHR system. The ID of the care request item is updated in serviceRequestsResponses of the preClaimSubmitInfo parameter.
            HealthCloudUtilizationManagementProviderRetrieveRecordIdByCode Data Mapper Retrieves the record ID from the provider system that matches the code received from the EHR system.
            HealthCloudUtilizationManagementProviderCreatePriorAuthRequest Data Mapper Creates a prior authorization request based on inputs retrieved from the provider’s EHR system.
            HealthCloudUtilizationManagementProviderPriorAuthCreationSetup Data Mapper Sets up the recordTypeId, careRequest, and claimBundleInputs details for creating a prior authorization request.
            HealthCloudUtilizationManagementProviderSubmitPriorAuthRequest Integration Procedure Submits the prior authorization request to the payer system.
            HealthCloudUtilizationManagementProviderPriorAuthSubmissionSetup Data Mapper Sets up the prior authorization request details for submission to the payer.
            HealthCloudUtilizationManagementProviderSavePriorAuthResponse Integration Procedure Saves the response that’s received on the prior authorization request from the payer system.
            HealthCloudUtilizationManagementProviderUpdatePriorAuthResponse Data Mapper Updates the prior authorization request with the response that’s received from the payer system.

            HealthCloudUtilizationManagementProviderInquiryRequest Omniscript

            Let’s see how this Omniscript's components manage the authorization request inquiry process to get the latest status of a request.

            Name Type Details
            HCUMInquiryFetchClaimDetails Data Mapper Retrieves information related to the case, care request, care request extension, and care request item records based on the Case ID.
            HCUMInquiryPatientDetails Data Mapper Retrieves details related to the patient account and identifier records based on the Patient ID.
            HCUMInquiryProviderDetails Data Mapper Retrieves the HealthCareProvider, HealthCareProviderNPI, and Identifier records record based on the Provider ID.
            HCUMInquiryInsuranceDetails Data Mapper Retrieves details of the member plan based on Member Plan ID.
            HCUMInquiryFetchPayorDetails Data Mapper Retrieves details of the payer based on payer ID.
            HCUMProvider_FetchInquiryBundle Integration Procedure Sets up the inquiry resource bundle for submitting an inquiry request on a case.
            HCUMProvider_SubmitInquiry Integration Procedure Uses the inquiry resource bundle and request ID as input to invoke an APEX remote action that performs an HTTP request callout to the payer. Also, this integration procedure returns claimResponse as output.
            HCUMProvider_OperationOutcome Integration Procedure Updates a single error string in OperationOutcomeError properties based on the error messages received from OperationOutcome MuleSoft API response.
            HealthCloudUtilizationManagementProvider_GenerateRequestId Integration Procedure Generates Request ID for a prior authorization request by appending timestamp to the logged in user's organization ID. This ID is required to make calls to the provider’s EHR system APIs.
            HealthCloudUtilizationManagementProvider_SavePriorAuthResponse Integration Procedure Saves the response that’s received on the prior authorization request from the payer system.
            HealthCloudUtilizationManagementProviderUpdatePriorAuthResponse Data Mapper Updates the prior authorization request with the response that’s received from the payer system.
            HealthCloudUtilizationManagementProvider_MergeFinalResults Integration Procedure Prepare the data for the authorization request summary using information from case, care request, account, and more.
            HealthCloudUtilizationManagementGetCaseDetails Data Mapper Retrieves the case details associated with the authorization request.
            HealthCloudUtilizationManagementProviderGetPatientAccountDetails Data Mapper Retrieves the patient details associated with the authorization request.
            HealthCloudUtilizationManagementProviderSelectedPatientDetails Flexcard Displays basic information of the patient for whom the authorization request is submitted.
            HealthCloudUtilizationManagementProviderAcknowledgment Flexcard Displays an acknowledgment message for the authorization request submission.
            HealthCloudUtilizationManagementProviderSubmissionFailedEmptyState Flexcard Displays an empty state image and message when the authorization request isn’t submitted.
            HealthCloudUtilizationManagementProviderInquiryLaunch Flexcard Starts the authorization request inquiry process.
            HealthCloudUtilizationManagementProviderInquiryRequestModal Flexcard Displays case summary and submits the inquiry request to the payer.
             
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