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Coverage Requirement Discovery for Payers
Support your users with automated workflows for managing coverage requirement discovery requests. Utilization Management processes incoming requests for coverage requirement discovery and returns responses using FHIR-aligned Clinical Decision Support (CDS) hooks such as the appointment-book, order-select, order-sign, order-dispatch, encounter-start, and encounter-discharge hooks.
Required Editions
Available in: Lightning Experience Available in: Enterprise and Unlimited Editions with Health Cloud |
Approving pre-authorization requests is often a time-consuming and complicated process, requiring multiple back-and-forths between payer and provider organizations. Coverage Requirement Discovery (CRD) helps in reducing the number of pre-authorization requests that payers receive by checking if members need pre-authorization in the first place. By submitting a coverage requirement discovery request for a member, a provider is asking a payer to:
- Validate the member
- Validate the member’s coverage
- Assess the need for pre-authorization for the requested service
- Check the required documentation
Coverage Requirement Discovery Using Clinical Decision Support
Payer organizations can use Clinical Decision Support (CDS) hooks to enable real-time access to member information, coverage details, and prior authorization requirements to providers, directly from their Electronic Health Records (EHR) system. The automation of coverage requirement discovery reduces time spent on administrative tasks, improves the chances of coverage approval, and helps in reducing human errors.
When a provider makes an API call to your CDS server, Clinical Decision Support fetches the list of services that you provide. This list is called Discovery Services. Each clinical decision support service is represented by an integration procedure with the type as HlsClinicalDecisionSupport.
If the requested service is in the list of supported services that you’ve defined, Clinical Decision Support invokes the corresponding integration procedure. For example, let’s say a member, Charles Green, needs hypertension medication. His provider, Bloomington Healthcare, sends a coverage requirement discovery request to check if pre-authorization is required and if this specific medication is covered under his plan.
When your CDS server receives this request, Clinical Decision Support identifies the requested service type as order echo and invokes the corresponding HlsClinicalDecisionSupportProcessOrderEcho integration procedure. Then, it validates if the request has all the required information. Finally, it uses Omnistudio components, Expression Sets, and Decision Matrices to evaluate whether Charles is eligible to be covered under his current health plan for the medication.
The integration procedure sends a response to the provider in the form of cards and system actions. This response includes information such as whether Charles is covered for the service under his plan, if he needs pre-authorization, additional documentation required, and more.
To learn more about the integration of clinical decision support hooks with EHR systems, see EMR Workflow Integration Using Clinical Decision Supports Hooks.
- Get to Know the Coverage Requirement Discovery Data Model
Coverage Requirement Discovery for Utilization Management uses a FHIR aligned-data model to store records in Health Cloud. - Get to Know the Omnistudio Components Related to Coverage Requirement Discovery
When you receive a CRD request, Health Cloud uses pre-built Omnistudio components to process the request, verify the member and coverage information, and send a response. These components power a smooth and swift request management and response workflow. - Prepare to Use Coverage Requirement Discovery for Utilization Management
To start using Coverage Requirement Discovery for Utilization Management, enable the feature in Setup and assign the required permissions. - Set Up Data to Use Coverage Requirement Discovery
To process and manage incoming coverage requirement discovery requests from providers, you need to ensure that your org has the required data. - Set Up FHIR-Aligned Picklist Values
Clinical Decision Support for Coverage Requirement Discovery processes member and coverage data in alignment with FHIR standards. Configure the picklist values for fields in the Service Information Request, Service Information Response, Service Information Response Coverage, and Service Information Response Resource URL following FHIR specifications. - Configure Page Layouts for Coverage Requirement Discovery Related Objects
Configure page layouts for the Service Information Request, Service Information Response, and Service Information Response Coverage objects. Help your users easily access the data they need by placing related lists and fields in the right places. - Configure Workflow to Determine Coverage Information Extensions
Use a decision matrix and expression set to automate the process of determining coverage information extensions for a coverage requirement discovery request. - Configure Integration Procedures for Clinical Decision Support Services
To implement automated workflows for managing different types of clinical decision support (CDS) services, clone and configure the prebuilt integration procedures for each CDS hook.
