Handle Care Requests with Utilization Management

Utilization Management (UM) is a health plan's way of working with plan members and medical providers to influence decisions via case-by-case review of the appropriateness of care.

• Supporting Utilization Management in Health Cloud
  Utilization Management (UM) is a health insurance plan's process of interfacing with plan members and contracted medical providers to interpret, administer, and explain the medical policies of the health plan. Health Cloud provides objects you can use to review and evaluate medical care services, communicate about clinical policies, and help health plan members ensure they receive the right care in the right setting at the right time.
• Authorization Request Overview
  Medications, surgeries, personalized therapies, and healthcare treatments can all lead to huge bills for payers and patients. Many of these expensive procedures can be avoided or replaced by simpler, cost-effective alternatives that take place in outpatient settings. To verify cost of care and medical necessity of procedures and treatments, payers must conduct authorization reviews of the care requests that providers raise.
• Manage Authorization Requests in a Payer’s Office
  Authorization for care requests typically requires a significant amount of administrative work, both by payers and providers. The review process can be tiresome and time-consuming, with multiple screen switches and data from various sources. To simplify and streamline this process, Utilization Management includes a number of guided workflows to help you handle authorizations efficiently.
• Manage Authorization Requests in a Provider’s Office
  Health Cloud’s Utilization Management ensures ease of access to information and smoother collaboration on authorization requests between payers, providers, and the Electronic Health Record (EHR) systems. This connected platform, with its highly refined OmniScript process workflows and uninterrupted information exchange, enhances payers' and providers' ability to expedite the authorization request process. Providers can now deliver timely and optimal medical care to patients by gathering necessary clinical information from the EHR system and submitting authorization requests to the payer system.
• CRM Analytics Dashboards for Utilization Management
  Use the analytics dashboards, including the Care Requests dashboards and the Approval Rate dashboard, to streamline care request management, prioritize prior authorization requests based on due dates, and get a consolidated view of key attributes associated with prior authorization requests. The personalized care requests dashboards for each user role offer quick insights to monitor and assess outstanding care request authorizations and reviews. The Approval Rate insight cards support quicker clinical reviews and decisions by providing relevant insights during the review process.
• Artificial Intelligence for Utilization Management
  Payers can see the predicted service-level agreement (SLA) breach scores for prior authorization review requests and the top factors that possibly contribute to SLA breaches on the Prior-Authorization Review SLA Breach Prediction dashboard. They can see services that they are likely to receive from providers and previously submitted services authorization requests for a member on the Recommended Services Pathway dashboard. Providers can see services that they are likely to request on the Recommended Services Bundling dashboard.