A payer needs to work with plan members and medical providers to influence decisions through...

Comprehensive Detailed Step by Step Explanation with exact Extracts from Salesforce Health Cloud documents that you have with References

Request Review Types:

Utilization Management processes center around reviewing requests for appropriateness of care, with the three main types beingPrior Authorization Review, Concurrent Review, and Retrospective Review.

Extract:

“Utilization Management supports prior authorization, concurrent, and retrospective reviews to evaluate care appropriateness case by case.”

—Utilization Management in Health Cloud

Care Requests:

Care Requests are the mechanism for providers to seek authorization from payers for drugs, services, or admissions.

Extract:

“Design care request processes to support providers seeking health plan authorization for services, medications, or admissions.”

—Health Cloud Utilization Management Data Model

Why not the other options?

A:Next Best Action is more for care management recommendations, not utilization review.

C:Intake agent count is an operational consideration, not a UM process.