A payer needs to implement a program to address the rising healthcare expenses and ensure affordable care for its members. The payer airs to strike a balance between quality care and managing the cost of care effectively by streamlining its approval processes for care requests.
Correct Answer:
A
Step 1: Requirement Analysis
Payer needs to manage healthcare expenses while ensuring quality, affordable care.
Seeks to streamline approval processes for care requests.
Step 2: Utilization Management in Health Cloud
Utilization Management (UM) provides workflows and automation for reviewing, approving, or denying care requests. This supports balancing cost controls with quality care through evidence-based review processes.
Extract:
''Utilization Management helps payers manage costs and ensure members receive appropriate care by streamlining the review and approval process for pre-authorizations and care requests.''
Administer Health Cloud -- Utilization Management
Step 3: Review of Options
A . Utilization Management: Directly addresses care request review, cost, and quality balance.
B . Provider Network Management: Focuses on managing provider networks, not utilization/cost review.
C . Intelligent Appointment Management: For scheduling only.
D . Integrated Care Management: Focuses on care coordination, not cost/approval workflow.
