Add Decision Explainer Messages to Prior Authorization Requests

Create Expression Set Message Tokens

1. From Setup, in the Quick Find box, enter Decision Explainer, and then select Expression Set Message Token.
2. Click New Expression Set Message Token.
3. Enter the expression set message token details.
   • Name: BenefitServiceCode.
   • Label: BenefitServiceCode.
4. Save your changes.

Create Explainability Message Templates

1. From Setup, in the Quick Find box, enter Decision Explainer, and then select Explainability Message Template.
2. Click New Explainability Message Template.
3. Enter the explainability message template details.
   • Name: BenefitServiceCode_Success.
   • Message: Prior authorization requirement for your service {BenefitServiceCode} is determined.
   • Expression Set Step Type: Decision Matrix Lookup.
   • Usage Type: Default. Label: BenefitServiceCode_Success.
   • Result Type: Passed.
4. Save your changes.
5. Similarly, create these explainability message templates.

   Name	Message	Expression Set Step Type	Usage Type	Label	Result Type
   BenefitServiceCode_Failure	Sorry! Prior authorization requirement for your service {BenefitServiceCode} could not be determined.	Decision Matrix Lookup	Default	BenefitServiceCode_Failure	Failed
   MemberPlanStatus_Success	Your Member Plan activation status is Active.	Calculation	Default	MemberPlanStatus_Success	Passed
   MemberPlanStatus_Failure	Your Member Plan activation status is Inactive.	Calculation	Default	MemberPlanStatus_Failure	Failed
   Approve_Success	This Member is Approved and PreAuthorised.	Calculation	Default	Approve_Success	Passed
   Approve_Fail	PreAuthorisation could not be determined for this member.	Calculation	Default	Approve_Fail	Failed

Add Decision Explanations to Expression Set Elements

1. From the App Launcher , find and select Expression Sets.
2. Click Member Plan Status Check.
3. On the Member Plan Status Check expression set record page, click the Member Plan Status Check V1 expression set version to open it in Expression Set Builder.
4. Click Deactivate.
   You must deactivate the expression set to make any changes.
5. Select the Benefit Service Code lookup table element.
6. Click on the left panel in the Expression Set Buildercanvas.
7. Select Show decision explanation.
8. Save your changes.
9. Click on the left panel in the Expression Set Builder canvas.
10. Select Show decision explanation.
11. In the Decision Explainer section, add these details.
    1. In When Step Returns Output, select BenefitServiceCode_Success.
    2. In When Step Errors, select BenefitServiceCode_Failure.
12. Click beside the When Step Returns Output field. Under Map Tokens, in BenefitServiceCode, select ServiceCode.
13. Click Done.
14. Click beside the When Step Errors field. Under Map Tokens, in BenefitServiceCode, select ServiceCode.
15. Click Done.
16. Save your changes.
17. Select the Member Plan Active calculation element, and click on the left panel.
18. Select Show decision explanation.
19. In the Decision Explainer section, add these details.
    1. In When Step Returns Output, select MemberPlanStatus_Success.
    2. In When Step Errors, select MemberPlanStatus_Failure.
20. Select the Prior Authorization Approval calculation element, and click on the left panel.
21. Select Show decision explanation.
22. In the Decision Explainer section, add these details.
    1. In When Step Returns Output, select Approve_Success.
    2. In When Step Errors, select Approve_Fail.
23. Save your changes.
24. Click Activate.

Simulate the Expression Set and View the Decision Explanation

Now, simulate the expression set and verify if the decision explanations you added earlier are appearing as expected. To simulate the expression set with context data, manually add the context input data as JSON inputs. Context data doesn’t hydrate automatically when you simulate an expression set.

1. From the App Launcher , find and select Expression Sets.
2. Click Member Plan Status Check.
3. On the Member Plan Status Check expression set record page, click the Member Plan Status Check V1 expression set version to open it in Expression Set Builder.
4. Click Simulate.
5. Select Advanced as the input mode.
6. In the JSON Input box, remove any existing data and add this sample test input data manually. You can copy and paste this code in the JSON Input box.

   {
     "ServiceCode": "CPT23456",
     "MemberNumberInput": "675858989",
     "DateOfService": "2024-09-26",
     "MemberPlan": [
       {
         "EffectiveDateTo": "2025-08-22",
         "EffectiveDateFrom": "2024-08-22",
         "PlanStatus": "Active",
         "CoverageBenefit": [
           {
             "CoverageBenefitItem": [
               {
                 "IsPreauthorizationRequired": "false",
                 "CoverageBenefitItemName": "XYZ",
                 "ServiceTypeCode": "CPT23456"
               }
             ]
           }
         ],
         "MemberNumber": "675858989"
       }
     ]
   }
   

7. Click Simulate.
8. From the Detailed View dropdown, select Concise View.