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 being Prior 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.