How to Use Business Rules Engine to Preapprove Health Cloud Care Requests

A Health Cloud customer is looking for an efficient end-to-end authorization process for patients to deliver timely care services. To achieve this, the customer’s authorization coordinator has to:

• Retrieve patient information from Electronic Health Records (EHR)
• Check the need for authorization for the requested services or diagnosis from the payer
• Create and submit authorization requests, with necessary details and documents, to the payer based on the defined requirements.
• Submit and follow up on the approval process with the payer
• Complete the process in a timely manner so that patient care is delivered as planned

Health Cloud’s Utilization Management feature provides the capabilities of centralized and guided workflows with multiple Omnistudio components and Business Rules Engine. It empowers users to easily manage healthcare prior authorization request submissions and reviews.

Before you begin, make sure that you have these settings and product licenses in your org:

• Health Cloud: Sign up for a Health Cloud Learning Org.
• Business Rules Engine
• Context Service
  • From Setup, in the Quick Find box, enter Context Service Settings, and then select Context Service Settings.
  • Enable the Context Definitions toggle.

Note This guide is based on the Salesforce Summer '24 release.

• Create Health Cloud Accounts
  Before you set up Business Rules Engine features with Health Cloud, create a few accounts with sample data that you can use when you configure the scenario.
• 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.
• Create a Context Definition for Health Cloud Objects
  Use Context Definition nodes and attributes to create a context definition for the Health Cloud objects and fields. Then, map the nodes with the corresponding objects, and map the attributes with the corresponding fields.
• Create a Decision Matrix for Benefit Service Codes
  Create a decision matrix to assign the prior authorization required status for the service codes defined in the Health Cloud objects and also for a few undefined ones.
• 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.
• Add Decision Explainer Messages to Prior Authorization Requests
  Create expression set message templates where you add the success and failure explanation messages for the elements you want to show the explanations. Then, assign these templates to the respective elements in the Expression Set Builder.
• Create a Flow for Prior Authorization Check
  A Salesforce Flow brings the Context Service and Business Rules Engine components on a single platform and helps you run the scenario to experience how these components work together to give the expected results. Create a flow to test the Health Cloud scenario and verify if you're getting the expected results. In this flow, you first add a screen component to capture the user inputs. Then, use the Get Records elements to fetch the Context IDs that you use to hydrate context data. Add a loop element to find the prior authorization and benefit details for each service code. Use a Build Context action element inside the loop to hydrate data from the Member Plan object and its child nodes. Then, add an action element to call the expression set that uses the hydrated data to get the prior authorization check status for each service code and the corresponding coverage benefit details and approval status.
• Run Health Care Prior Authorization Check Scenario
  Run the Health Care Prior Authorization Check flow to execute the Prior Authorization scenario and experience how Business Rules Engine performs calculations and provides the results.