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Automate Workflows with Predefined Rules
Simplify and expedite reviews of authorization requests by using built-in business rules and logic. Use the predefined expression set templates and define decision matrices to perform automatic validation, reduce administrative errors, and cut down on repetitive tasks.
Required Editions
Available in: Lightning Experience Available in: Enterprise and Unlimited Editions with Health Cloud |
| User Permissions Needed | |
|---|---|
| To define decision matrices and expression sets: | RuleEngine Designer permission set |
Utilization Management provides these prebuilt expression set templates that are readily integrated with the Omniscript processes:
- HealthCloudUM_AutoApproval - Validates if an authorization request can be auto-approved without reviews
- HealthCloudUM_DocsChecklist - Validates if an authorization request includes the required clinical documents
- HealthCloudUM_NeedAssessment - Validates if the diagnostic and service codes requested in an authorization require approval
In tandem with these predefined expression set templates, you must define a set of decision matrices to obtain rule-based workflow automation.
- From the App Launcher, find and select Lookup Tables.
- Click New, select Decision Matrix, and then click Next.
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Use the following table to define the required decision matrices:
- Enter the name for the decision matrix.
- Set the Type as Standard.
- Click Save.
- Select the Related tab and then open the decision matrix version.
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Click Add Column to input and output columns for each decision
matrix as specified, and then save your changes.
Decision Matrix Name Purpose Columns for Input Data Columns for Output Data HealthCloudUM_DocsChecklist Defines the list of mandatory documents required for a request type and region. - RequestType (Text)
- Region (Text)
Files (Text) 
Note Provide a comma-separated list of document names.NeedAssessmentRuleIndividualPlanConditions Indicates if authorization is required for a member who has an individual member plan. - ServiceCode (Text)
- RequestType (Text)
- PlanName (Text)
- City (Text)
- State (Text)
Output (Text) - Required
- NotRequired
NeedAssessmentRuleGroupPlanConditions Indicates if authorization is required for a member who has a group member plan. - ServiceCode (Text)
- RequestType (Text)
- PlanName (Text)
- City (Text)
- State (Text)
Output (Text) - Required
- NotRequired
HealthCloudUM_AutoApproval Indicates if authorization requests with a combination of specific input parameters can be automatically approved. - RequestType (Text)
- ServicingProviderInNetwork (Boolean)
- ServiceCode (Text)
- IsMemberActive (Boolean)
- MemberPlanLOB (Text)
IsAutoApproved (Boolean)
- Add rows and values for each decision matrix, and then save your changes.
- Edit the decision matrix version and set it to Active.
- Save your work.
- From the App Launcher, find and select Expression Set Templates.
- Save new versions of each of these predefined expression set templates with the same name: HealthCloudUM_AutoApproval, HealthCloudUM_DocsChecklist, and HealthCloudUM_NeedAssessment.
- From the Expression Set Properties, set the rank as 1.
- Save and activate the expression set.
Now, when your users create and review authorization requests, the Omniscript process refers to the predefined rules and validates the request details.
