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            Create an Expression Set for Prior Authorization Determination

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            Create an Expression Set for Prior Authorization Determination

            Use an expression set to create a rule to determine the prior authorization and member plan status of a service. Add a List Group element in the expression set to fetch the Health Cloud object fields from the context definition that you created earlier. Based on the prior authorization and member plan status, calculate the coverage benefit associated with the service and its approval status.

            Required Editions

            Available in: Lightning Experience
            Available in: Enterprise and Unlimited Editions for clouds that have Business Rules Engine enabled
            User Permissions Needed
            To create, update, and delete expression sets Rule Engine Designer
            To run expression sets in Business Rules Engine Rule Engine Runtime
            1. From the App Launcher App Launcher, find and select Expression Sets.
            2. Click New.
            3. Enter Member Plan Status Check as the name of the new expression set.
            4. Select Default as the usage type.
            5. Select Get_MemberPlan_Details as the context definition.
            6. Save your changes.

            Create Resources

            1. 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.
            2. In the Expression Set Builder, open Resource Manager by clicking Resource Manager Icon.
            3. Click Add Resource.
            4. To create the Date of Service variable, enter these details.
              • Resource Type: Variable
              • Resource Name: DateOfService
              • Data Type: Date
            5. Click Done.
            6. Similarly, create these variables.
              Resource Type Resource Name Data Type
              Variable MemberNumberInput Text
              Variable MemberPlanStatus Boolean
              Variable PriorAuthDetermination Text
            7. Save your changes.

            Add Elements

            1. In the Expression Set Builder canvas, click Add Elements Icon.
            2. Find and select Lookup Table.
            3. In the Lookup Table Details field, find and select the Benefit Service Code decision matrix.
            4. Save your changes.
              Benefit Service Code
            5. Click Add Elements Icon after the Benefit Service Code lookup table element.
            6. Find and select List Group.
            7. Add these details in the List Filter element.
              1. Rename the List Filter element as Check Member Plan Status.
              2. In Filter Condition Requirements, select All Conditions Are Met (AND).
              3. Select MemberNumber as the resource.
              4. Select Equals as the operator. Select MemberNumberInput as the value.
              5. Click Add Condition.
              6. Select PlanStatus as the resource.
              7. Select Equals as the operator.
              8. Enter Active as the value.
              9. Click Add Condition.
              10. Select EffectiveDateFrom as the resource.
              11. Select Less Than as the operator.
              12. Select DateOfService as the value.
              13. Click Add Condition.
              14. Select EffectiveDateTo as the resource.
              15. Select Greater Than as the operator.
              16. Select DateOfService as the value.
            8. Click Add Elements Icon inside the List Group box.
            9. Find and select Calculation.
            10. Add these details in the calculation element.
              1. Rename the Calculation element as Member Plan Active.
              2. Enter true as the formula.
              3. Select isMemberPlanActive as the output variable.
            11. Click Add Elements Icon inside the List Group box.
            12. Find and select Calculation.
            13. Add these details in the calculation element.
              1. Rename the Calculation element as Member Plan Status.
              2. Select isMemberPlanActive as the formula.
              3. Select MemberPlanStatus as the output variable.
            14. Save your changes.
              List Group 1
            15. Click Add Elements Icon outside the List Group box.
            16. Find and select List Group.
            17. Add these details in the List Filter element.
              1. Rename the List Filter element as Check Requested Code with Plan Condition 1.
              2. In Filter Condition Requirements, select Any Condition Is Met (OR).
              3. Select IsPreauthorizationRequired as the resource.
              4. Select Equals as the operator.
              5. Enter false as the value.
              6. Click Add Condition, and add two more conditions with these details.
                Resource Operator Value
                Benefit_Service_Code__PriorAuthorizationRequired Equals false
                ServiceTypeCode Not Equals ServiceCode
            18. Click Add Elements Icon inside the List Group box.
            19. Find and select Calculation.
            20. Add these details in the calculation element.
              1. Rename the Calculation element as Prior Authorization Not Required.
              2. Enter ServiceCode + " " + CoverageBenefitItemName + " - Administrative Not Approved, PriorAuth Not Required or Service Code is not covered for Benefit." as the formula.
              3. Select PriorAuthDetermination as the output variable.
            21. Save your changes.
              List group 2
            22. Click Add Elements Icon outside the List Group box.
            23. Find and select List Group.
            24. Add these details in the List Filter element.
              1. Rename the List Filter element as Check Requested Code with Plan Condition 2.
              2. In Filter Condition Requirements, select Custom Condition Logic is Met. For Custom Condition Logic, enter (1 OR 2) AND 3.
              3. Select IsPreauthorizationRequired as the resource.
              4. Select Equals as the operator.
              5. Enter true as the value.
              6. Click Add Condition, and add two more conditions with these details.
                Resource Operator Value
                Benefit_Service_Code__PriorAuthorizationRequired Equals true
                ServiceTypeCode Equals ServiceCode
            25. Click Add Elements Icon inside the List Group box.
            26. Find and select Calculation.
            27. Add these details in the calculation element.
              1. Rename the Calculation element as Prior Authorization Approval.
              2. Enter ServiceCode + " " + CoverageBenefitItemName + " - Administrative Approved" as the formula.
              3. Select PriorAuthDetermination as the output variable.
            28. Save your changes.
              List Group 3
            29. Click Settings Icon in the Expression Set Builder page.
            30. Enter 1 as the rank.
            31. Select the Prior Authorization Approval element.
            32. Click Expression Set Builder Icon in the Expression Set Builder page.
            33. Select Include in Output.
            34. Similarly, select Include in Output for all the calculation elements and lookup table element in the expression set.
            35. Save your changes.
            36. Click Activate.
             
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