Utilization Management configuration for payers and providers
Key Takeaway
Utilization Management has two separate setups, one for payers and one for providers. Both start with the same prerequisites.
Utilization Management (UM) uses managed care techniques such as prior authorization (PA) so payers can check whether a benefit is appropriate before it is provided, using evidence-based criteria or guidelines. PA is the process for deciding whether a medical procedure or service is medically necessary and covered under the patient's insurance plan. UM aims to give patients the right care, at the right time, for the right duration, in the right setting. In Agentforce Health, the payer setup covers intake, clinical review, and decision on authorization requests. The provider setup covers need assessment (checking whether a service needs PA) and electronic submission of requests to the payer, using data pulled from the Electronic Health Record (EHR).
Prerequisites for both setups
The payer setup and the provider setup start with the same prerequisites:
- Enable person accounts.
- Install Omnistudio.
- Assign the correct permission sets and permission set licenses.
- Set up the relevant data in the org.
You must finish "Set Up Permissions and Data for Utilization Management" before you start either the payer or the provider process setup. Guided setup instructions are on the "Utilization Management Settings" page under Setup.