A payer is implementing Health Cloud and wants to leverage predefinedrules for its prior authorization...

Step 1: Requirement Analysis

The payer wants to usepredefined rulesfor prior authorization request reviews, seekingout-of-the-box Health Cloud functionalityfor speed to value.

Step 2: Health Cloud Prior Authorization & Rules Engine

TheExpression Set Templatesin Health Cloud provide a prebuilt, configurable framework to automate and standardize prior authorization request reviews. These templates contain reusable logic and criteria that can be easily tailored and applied to common authorization scenarios.

Extract:

“Use Health Cloud’s prebuilt Expression Set Templates to accelerate prior authorization configuration. These templates enable payers to implement standardized review criteria and automate decision logic without building rules from scratch.”

Administer Health Cloud – Utilization Management and Expression Sets

Integration Procedures,FlexCards, andOmniScript Templatesare OmniStudio tools for integration, UI, and guided processes, butExpression Set Templatesare the feature specifically designed for rules automation in Utilization Management.