Utilization Management design for payers versus providers
Key Takeaway
Utilization Management design depends on which side of a prior authorization request the customer is on: providers check whether it's needed and submit requests, while payers take in, review, and decide on them.
Utilization Management (UM) in Agentforce Health supports prior authorization (PA), the process for deciding whether a medical procedure or service is medically necessary and covered under the patient's insurance plan. The customer's side decides which users, guided flows, and tools the design uses.
Need assessment
The UM process usually starts with need assessment, where the provider works out whether a service needs a PA request.
If PA isn't required...
The provider can perform the service right away with the assurance that it will be covered.
If PA is required...
The provider submits a request to the patient's insurer.
Need assessment rules and auto-approval belong to the payer, even in a provider-led flow. The payer uses Business Rules Engine (BRE), with prebuilt rule templates, to decide whether a service needs PA. Auto-approval rules either give an instant determination or send the request to a full clinical review.