Utilization Management for prior authorization and care request review
Key Takeaway
Utilization Management has two sides with separate setups: providers decide whether a service needs prior authorization and submit the request, then payers review it and make the decision.
Utilization Management (UM) is how a health plan (the payer) reviews requested care case by case to decide whether it is appropriate before it is provided. UM uses managed care techniques such as prior authorization (PA) to assess a benefit against evidence-based criteria or guidelines. The goal is the right care, at the right time, for the appropriate duration, in the right setting, while payers manage the cost of health care benefits. In Agentforce Health, UM gives payers and providers a shared data model, guided OmniStudio workflows and Business Rules Engine automation to submit, review and decide on care requests.
Two sides with separate setups
UM has two sides, and each side has its own setup. Providers decide whether a service needs PA, then create and submit the authorization request. Payers take in the request, review it and make the decision.
The payer and provider authorization request processes are available in Lightning Experience, in Enterprise and Unlimited Editions.