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How Reverification Automation Works
Pharmacy benefits reverification automation saves time and resources of pharmaceutical companies by streamlining patient benefit updates. Automation helps control expenses and prevent fraud for both providers and patients, so that continuous, accurate, and cost-effective pharmacy benefits are provided through electronic and manual verification processes.
Required Editions
| Available in: Lightning Experience |
| Available in: Enterprise and Unlimited Editions with the Health Cloud or Life Sciences Cloud license. It's also available with these add-on licenses: Agentforce for Life Sciences Cloud or Agentforce for Health Cloud, Flex Credits Metering, Agentforce Employee Agent, Einstein GPT Platform, Einstein GPT Copilot, Einstein GPT Trust, Genie Data Platform Starter, and Einstein GPT Prompt Builder. |
Here are the different stages of reverification automation.
Update Patient Personal and Healthcare Details
Updating a patient's personal and healthcare details is crucial for reverification automation. This orchestration stage helps identify changes in a patient's personal and healthcare details and establishes accurate, continuous pharmacy benefits.
- Send Email to Patient: This step waits for you to use Agentforce to send an email containing an assessment URL to the patient. After you send the email and update the care benefit verify request status to Pending Confirmation, the step is marked as Completed.
- Wait for Patient Response: After you send the email to the patient, automation waits for their response. After the patient responds, the Care Benefit Verify Request status is updated to Received Confirmation and the step is marked as Completed.
- Update Patient Details: This step waits for you to use Agentforce to update the patient's details based on the responses received. After you update patient details, the care benefit verify request status is updated to Ready For Verification and the step is marked as Completed.
Process Electronic Verification Request
This orchestration stage sends an electronic request to a clearing house to gather a patient’s benefit details, validates the response for essential benefits, and then shares the benefits summary with a healthcare professional (HCP).
- Initiate Electronic Verification Request: If the verification mode of the care benefit verify request record is electronic, an electronic verification request is sent to a third-party clearing house. The third-party clearing houses then connect with payors to get the latest benefits details such as Copay, Coinsurance, and Life Time Maximum (LTM). The care benefit verify request status is updated to Acknowledged upon acknowledgment from the clearing house. When a valid response is received from the payor, the status is updated to Verified, and the step is marked as Completed.
- Validate Essential Benefits: After receiving the response from the clearinghouse, the essential benefits, such as Copay, Coinsurance, and LTM, are verified in the payor's response. If the payer's response includes the essential benefits, the care benefit verification request status is updated to Completed.
- Send Email to Healthcare Professional: If all essential benefits are present in the payor's response, a summary of the patient's benefit details is shared with the Healthcare Professional (HCP).
Process Manual Verification Request
If the verification mode of Care Benefit Verify Request is manual, or if the payor's response to an electronic verification request is missing essential benefits, the automation proceeds with the manual verification process.
- Send Email To Payor: An email with a secure assessment URL is sent to the payor to confirm the patient’s latest benefits details.
- Wait For Payor Response: After sending the email to the payor, automation awaits a response from the payor.
- Validate Essential Benefits: If all essential benefits are present in the payer response, the care benefit verification request is marked as Completed.
- Send Email to Healthcare Professional: If all essential benefits are present in the payor's response, a summary of the patient's benefit details is shared with the Healthcare Professional (HCP).
