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Health Cloud supports Utilization Management (UM) through the Service Request object, which tracks prior authorization requests, and through integration with electronic prior authorization systems using MuleSoft.

Customize the Service Request object:

Extract:

“The Service Request object is at the core of the Utilization Management process in Health Cloud. You can customize fields, page layouts, and automation to match your business processes for prior authorization.”

(Source: Administer Health Cloud – Utilization Management)

Integrate using MuleSoft Direct for ePA:

Extract:

“Integrate Health Cloud Utilization Management with external systems using MuleSoft Direct, enabling electronic submission and tracking of prior authorizations.”

(Source: Administer Health Cloud – Utilization Management Integration)

Why not B or D?

There is no standard custom setting called UtilizationManagementSettings for this process.

Support Process is more for standard Salesforce Cases and not directly linked to Utilization Management flows in Health Cloud.

Step-by-Step Explanation:

Person Account as Patient Model:Salesforce Health Cloud is designed to leverage the Person Account model to represent patients, especially for large provider systems.

Exact Extract:

“Health Cloud uses person accounts to represent patients as individuals with whom you do business. Person accounts combine the functionality of accounts and contacts into a single record.”

Step 1: Understanding the Discovery Framework in Health Cloud

The Discovery Framework in Salesforce Health Cloud is designed to streamline intake and clinical assessments by providing reusable, modular, and compliant tools for healthcare organizations. It enables organizations to collect, store, and reuse responses to assessment questions efficiently and securely.

When onboarding Health Cloud into an org that already uses Service Cloud, it’s critical to properly configure Organization-Wide Defaults (OWD) to ensure that protected health information (PHI) remains restricted.

The correct settings are:

A. Set Person Accounts to Private

Patients are modeled as Person Accounts in Health Cloud.

Setting Person Accounts to Private ensures PHI isn’t exposed to users outside the Health Cloud business unit.

B. Set related clinical objects to Controlled by Parent or Private

Clinical objects (e.g., Care Plans, Assessments, Referrals) often relate to patients.

Making them Controlled by Parent (Person Account) or Private ensures only authorized users can see PHI.

E. Set Health Details to Controlled by Parent or Private

Health Details contain sensitive clinical data.

Must be restricted at the OWD level to prevent exposure to non-Health Cloud users.

Why not the others?

C. Set Account and Contract to Private

Regular business Accounts/Contracts are part of Service Cloud, not typically where PHI resides. Restricting them isn’t required for PHI protection.

D. Set Contact to Controlled by Parent

Contacts in Health Cloud are often caregivers or providers, not patients (who are Person Accounts).

PHI protection centers around Person Accounts + Clinical Objects + Health Details, not Contacts.

Salesforce Health Cloud Reference:

???? Salesforce Health Cloud Security and Sharing Guide:

“For HIPAA and other PHI compliance, set Person Accounts and Health Cloud clinical objects to Private or Controlled by Parent.”

“Ensure Health Details are not exposed via default sharing.”

Step-by-Step Explanation:

Supported Data Exchange Standards:Health Cloud natively supports modern clinical data standards such as FHIR R4 and traditional messaging formats like HL7 v2 for interoperability and data exchange.

Exact Extract:

“Health Cloud supports industry standards for data exchange, including FHIR R4 and HL7 v2, to enable clinical interoperability with EHR systems and other healthcare platforms.”

Step 1: Understanding the Requirement

A payer organization needs to recruit, credential, and onboard providers into its network. This requires features that manage provider information, credentialing processes, onboarding workflows, and network directory maintenance.

Step 2: Official Salesforce Health Cloud Capability

Salesforce Health Cloud offers an add-on called Provider Network Management (PNM) that is specifically designed for payers to recruit, credential, and onboard providers.

Extract:

“Provider Network Management streamlines recruiting, credentialing, onboarding, and network directory maintenance for payers. It provides tools to manage the provider lifecycle from initial recruitment through onboarding and network management.”

Administer Health Cloud – Provider Network Management

Step 3: Review of Options

A. Contact Center for Payers: Focused on member and provider service center functionality, not recruiting or credentialing.

B. Utilization Management: Focused on authorization and medical necessity reviews, not onboarding or credentialing.

C. Provider Network Management: Specifically built for recruiting, credentialing, and onboarding providers.

D. Provider Relationship Management: Focuses on relationship management post-onboarding, but not credentialing/onboarding workflows.

The Discovery Framework in Health Cloud supports:

Question Bank: Central repository of reusable questions for assessments.

Branching: Dynamic branching logic based on patient responses.

Scoring: Automatic scoring for assessments/intakes.

Extract:

“The Discovery Framework supports Question Bank, branching logic, and scoring for dynamic, reusable clinical assessments.”

(Source: Administer Health Cloud – Discovery Framework)

Encrypted Text and Image Analysis are not functions of the Discovery Framework.