Use case 5 - Benefits and eligibility verification
The MuleSoft Accelerator for Healthcare now enables call center agents and care staff to perform real-time benefits and eligibility verification. Providers can electronically verify a patient’s insurance coverage in real-time for medical treatment directly within Salesforce Health Cloud.
Benefits and eligibility verification is the process that allows providers to verify a patient’s insurance coverage for medical treatment. The Benefits Verification API directly pulls the necessary coverage information from major eligibility providers into a system of engagement like Salesforce Health Cloud. This enables call center agents and care staff to verify and access insurance coverage in real-time within a single platform.
- The users of this functionality will need access to the patient's demographic information (name, date of birth, gender), insurance coverage information (health plan, subscriber ID), and practitioner information (national practitioner identifier - NPI)
- The primary system of record for the patient’s demographic information as well as the plan information is the Electronic Medical Record (EMR) system, such as Epic or Cerner. The assumption is that this data is either already synced or could be synced on-demand with the system of engagement, such as Salesforce Health Cloud.
- The administrative staff at the healthcare provider’s office wants to verify benefits and eligibility for the patient.
- The staff member logs into system of engagement (such as Salesforce Health Cloud) and navigates to the Patient Engagement Console.
- The patient’s record is looked up in EMR (Cerner) using the search functionality provided by the lightning web component.
- Once the record is pulled up from Cerner, the staff member opens it and clicks the Patient sync button to sync the patient demographics.
- The staff member clicks the Verify Benefits button to load coverage information into the system of engagement, such as Salesforce Health Cloud.
- When the benefits are successfully verified, a success message appears on the screen.
- The benefit verification results should be available in the MemberPlan entity in Health Cloud.
- The MemberPlan entity can then be opened in Health Cloud where the benefits and eligibility information is available.
Use case benefits
- Administrative and clinical staff are enabled to deliver more seamless patient experience and avoid use of multiple systems through the use of the API-based benefits and eligibility verification.
- The staff can then use the single screen/application to perform their job and avoid the constant need of switching between different applications. Unlike phone/fax-based benefits and eligibility verification, API-based verification is instantaneous. This improves the productivity of clinical staff, as well as results in a better patient experience.
- Cerner Financial System API | API Specification | Implementation Template
- Epic Financial System API | API Specification | Implementation Template
- Benefits Eligibility Verification System API | API Specification | Implementation Template
- Health Cloud Financial System API | API Specification | Implementation Template
- Health Cloud Benefits Verification Lightning Web Component | Source