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Understand the Utilization Management Data Model

Learning Objectives

After completing this unit, you’ll be able to:
  • Describe the Health Cloud utilization management data model.
  • Explain the purpose of different objects used in the utilization management data model.

Introduction

Utilization management (UM) is all about how a health insurance plan is used as the basis for plan members and care providers to deliver the right services, at the right time, according to the medical policies of the health plan.

The utilization management data model is a set of data objects you can use to evaluate:
  • Preauthorization requests
  • Prescription or medical service requests
  • Admission cases
  • Concurrent or continued stay reviews
  • Appeals, complaints, and grievances

This diagram illustrates the utilization management data model. For more details about each object, see the Salesforce Health Cloud Developer Guide.

Diagram that illustrates the utilization management data model.

Explore the Utilization Management Data Model

Dr. John Bostworth, Charles Green’s primary care physician, diagnoses Charles with lower back pain and refers him to physical therapist Carol Petersen. Based on the recommendation from Dr. Bostworth, Charles visits Carol. She examines him and determines that 10 physical therapy sessions would help his lower back pain.

Carol submits a preauthorization request for the Physical Therapy sessions to Bloomington Health Plans, Charles’s health insurance provider. Carol provides all the necessary details that Bloomington Health Plans needs so that they can evaluate the request.

The Care Request then gets assigned to Melinda Smith, a utilization management nurse at Bloomington Health Plans. Melinda looks at Charles Green’s care request (Care Request). She sees that Charles is suffering from an acute lower back problem (Care Diagnosis). Melinda also sees that Carol Petersen has advised 10 physical therapy sessions (Care Request Item) to alleviate his pain.

Melinda then looks at Charles’s insurance policy, which confirms that Charles is covered for physical therapy. However, digging into Charles’s claims records, she notices he’s already reached the maximum claim limit allowed, which is 30 physical therapy visits per year.

Carol is recommending 10 Physical Therapy sessions for Charles

Melinda thinks she needs to deny the request. As she looks deeper into the situation, she sees that the physical therapy sessions are medically necessary for Charles. Melinda needs to ensure that the appropriate course of action is taken. She decides to escalate Charles’s case to the Medical Director at Bloomington Health Plans, Dr. Barbara Brown.

Dr. Brown looks at Charles’s care request information. After going through his condition and medical history, she determines that the physical therapy sessions are indeed a medical necessity for Charles, so she approves the care request.

This diagram illustrates how Charles’s scenario fits into the Utilization Management data model.

Diagram that illustrates how Charles’s care request scenario fits into the Utilization Management data model.

Here’s a look at the records, objects, and relationships in the utilization management data model based on Charles’s scenario.

This Record... ...Is Related To
Care Request Details (Care Request) Care Request Case (Case)
Care Request Case (Case) Charles Green—Patient (Person Account)
Lower Back Pain (Care Diagnosis) Care Request Details (Care Request)
Physical Therapy x10 (Care Request Item) Care Request Details (Care Request)
Lower Back Pain (Care Diagnosis) ICD-10-CM Code M54.5 (Healthcare Diagnosis)
Physical Therapy x10 (Care Request Item) CPT Code 97110 (Healthcare Procedure)
Care Request Details (Care Request) Carol Petersen, Requesting Practitioner (Contact)
Care Request Details (Care Request) Carol Petersen—Servicing Practitioner (Contact)
Care Request Details (Care Request) John Bostworth, General Practitioner (Contact)
Care Request Details (Care Request) Melinda Smith, First Reviewer (User)
Care Request Details (Care Request) Barbara Brown, Medical Director (User)

Now that you’ve completed the virtual tour of Charles’s Health Cloud journey, you know about the various data models available in Health Cloud, and the purpose of the objects within those data models. You now have the knowledge required to help you adopt, implement, and customize Health Cloud for your business needs. Congratulations! You can now enable your business to efficiently connect patients with the care they need.