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Business Rules Engine
Create Plans and Benefits

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Create Plans and Benefits

Create Member Plans, Purchaser Plans, Coverage Benefits, and Coverage Benefit Items to ensure that the Health Cloud prior authorization workflow accurately reflects the rules and coverage details required to assess user eligibility and calculate benefits. These objects are the data sources for context definition and Business Rules Engine.

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 member plan records: Health Cloud Foundation (for Health Cloud) permission set
To create purchaser plan records: Health Cloud Foundation (for Health Cloud) permission set
To create a coverage benefit: Health Cloud Starter OR Health Cloud Foundation
To create a coverage benefit item: Health Cloud Starter OR Health Cloud Foundation

Purchaser Plan

  1. From the App Launcher (App Launcher), find and select Purchaser Plans.
  2. Click New.
  3. Add these details.
    • Name: Cigna Medicare Purchaser Plan
    • Payer: Cigna International
    • Plan Number: P1234567
    • Plan Type: Medicare
    • Plan Status: Active
    • Effective From: [Current Date]
    • Effective To: [Future Date]
  4. Save your changes.

Member Plan

  1. From the App Launcher (App Launcher), find and select Member Plans.
  2. Click New.
  3. Add these details.
    • Name: Cigna Medicare Advantage Plan
    • Member: Steve Smith
    • Member Number: 675858989
    • Group Number: 7878787878
    • Plan: Cigna Medicare Purchaser Plan
    • Payer: Cigna International
    • Subscriber: Victor Kent
    • Effective From: [Current Date]
    • Effective To: [Future Date]
    • Status: Active
    • Verification Status: Active - Verified
    • Relationship to Subscriber: Spouse
  4. Save your changes.

Coverage Benefit

  1. From the App Launcher (App Launcher), find and select Coverage Benefit.
  2. Click New.
  3. Add these details.
    • Name: Medicare Coverage Benefit
    • Member: Steve Smith
    • Member Plan: Cigna Medicare Advantage Plan
  4. Save your changes.

Coverage Benefit Item

  1. From the App Launcher (App Launcher), find and select Coverage Benefit Item.
  2. Click New.
  3. Add these details.
    • Name: Cardiovascular Monitoring Services
    • Member: Steve Smith
    • Coverage Benefit: Medicare Coverage Benefit
    • Service Type Code: CPT23456
    • Save your changes.
  4. Similarly, create coverage benefit items with these details.
    Name Member Coverage benefit Service Type Code
    Echocardiography Procedures Steve Smith Medicare Coverage Benefit CPT23457
    Non-invasive Physiologic Studies and Procedures Steve Smith Medicare Coverage Benefit CPT23458
    TMT Test Steve Smith Medicare Coverage Benefit CPT23459
 
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