Set Up Utilization Management

Learning Objectives

After completing this unit, you’ll be able to:

• Understand the prerequisites needed to configure utilization management.
• Learn how to set up utilization management.

Prerequisite Installations and Permissions

Before you set up utilization management (UM), you must put some preparations in place.

First, install the Health Cloud managed package. Health Cloud is a managed package installed on top of Service Cloud, and this managed package delivers the core features of Health Cloud. The UM objects are installed as part of the standard objects. See Install Health Cloud for instructions on how to install the package.

Next, install the Health Cloud Care Request Extensions unmanaged package. This unmanaged package contains an app with the record types, page layouts, and other metadata to support utilization management. You can install it from http://industries.force.com/healthcloudextensioncarerequest.

Finally, assign the Health Cloud Permission Set Licenses. Health Cloud provides special permission sets that assign the permission set licenses that you need to use specific Health Cloud features. This includes the Health Cloud Platform permission set license, which grants read access to health insurance records and create, read, and update access to utilization management records. See The Health Cloud Utilization Management Permission Set to learn more.

Create Care Request Configuration

Now that you have the foundation, it’s time to put together the care request configuration. Set up the care request configuration for the business process that you want to create the care request for, such as requests for admissions, therapy sessions, and so on.

You can configure care requests one of these two ways.

• Use Care Request Settings from Setup.
• Create screen flows to first create the case, and then create the care request.

To configure care requests, first define a record type for each type of care request your company uses. Next you associate the record type to the Case and Care Request objects. 

Let’s create the care request configuration using Care Request Settings. 

1. From Setup, enter care request settings in the Quick Find box, then select Care Request Settings.
2. Click New Care Request Configuration.
3. Enter a label for the new care request type. The name auto populates with the value you enter.
4. Select the Care Request Type from the list and enter the name of the Care Request Record Type.
5. Select the records you want to use to configure the care request.
6. Select Active to activate this configuration and make it available to users.
7. Select Default record type if you want to make this record a default record type.
8. Click Save.
   

Add as many care request types as you want by using the same procedure. 

Add the Care Request Component

The next step is to make the care request component available on the UM console or the Experience Cloud site so that the provider staff (Carol) and the UM clinician (Melinda) can submit, review, and track preauthorizations requests. 

Let’s add the care request to the Home page of the UM console.

1. In the UM app, select Home from the navigation menu.
2. From Setup, select Edit Page.
3. In the Lightning App Builder, drag the Create Care Request component (1) on the Home page (2).
4. All the care requests you configured are available in the Care Request Configuration dropdown (3). Select the one you want to add to the Home page. You can add any other care request configurations that you want to appear on the Home page.
   

Add Care Request Details to the Case Layout

For each case submitted, you can see the care request details such as the member information and provider information. You can also see the review details such as criteria met, determinations, and notification information. You can add details to show information from each of the UM record types.

Now Melinda gets a true 360-degree view of the member when she reviews a request.

As she determines if a request is appropriate for the member and shows evidence of medical necessity, she is able to view all the information submitted with the request. She also can access other data such as member benefits, existing authorizations, internal policies, and guidelines.

Let’s see how to add the care request details to the case layout.

1. In Setup, search for App Builder, and then select Lightning App Builder.
2. In the Lightning Pages list, click Edit next to the Case Record Page.
3. Add a new tab called Care Request Details (1). You can rename the tab to anything you want (2).
   
   
4. Drag the Care Request Details component in the tab area (1). You can create additional tabs and choose the record detail (2) you want to display on the page.
   

The Finishing Touches

You’ve successfully configured and added UM components. To make the experience even easier for your users, you can customize the page by adding the path bar, which shows the stages of the care request process based on values in the Status field of the case.  

Now UM clinicians and medical directors can achieve process efficiency and make calculated decisions to benefit their members and their organization. 

Resources 

• Salesforce Help: Utilization Management Setup Checklist