Prior Authorization with Salesforce

The Challenge

Prior authorization volume keeps growing. Clinical review staff isn't growing with it. And every request now sits on a public clock.

Here's what UM teams are up against:

Deadlines at Volume

Fax and portal intake means requests sit in inboxes before anyone touches them. When volume spikes, the 72-hour and 7-day windows get harder to hit, and nobody can see which requests are at risk until it's too late.

Inconsistent Review

When every reviewer works from their own process, clinical criteria get applied differently from case to case. That inconsistency creates risk and frustrates providers.

Provider Abrasion

Providers make repeated calls and send repeated faxes just to check status. That's a lot of hours per week on their side, and a lot of call volume on yours.

Gaps That Surface in Audits

Missing documentation and unclear decision trails tend to show up at the worst possible moment, during a CMS compliance review. Now that metrics are public, those gaps are visible to everyone.

The Solution

We build a prior authorization operation where routine work clears itself and reviewers spend their time on cases that need clinical judgment.

One Complete Member Record

Health Cloud serves as the system of record for every request. Each one links to the member, the submitted clinical documentation, and the requesting provider, so reviewers aren't hunting across systems to make a decision.

Automatic Triage

Flow and Apex automation handles intake from the provider portal, fax-to-digital conversion, or EDI feeds. Each request is checked against your configured clinical criteria. Straightforward requests are approved automatically. Complex ones route straight to the right clinical reviewer.

Deadline Tracking

Countdown timers built with Flow and Platform Events track every 72-hour and 7-day clock. Staff and supervisors get alerts before a deadline is at risk.

Secure Data Exchange

MuleSoft builds and exposes the FHIR-based Prior Authorization, Provider Access, and Payer-to-Payer APIs required under CMS-0057-F. It connects Health Cloud to your core claims and eligibility systems, so authorization data moves between you, providers, and other plans without manual transfers.

Audit-Ready Reporting

Data 360, optionally paired with Snowflake, unifies claims, clinical, and prior authorization data to power public metrics and internal audit dashboards. Field history tracking in Health Cloud records every decision and the criteria behind it.

The Results

Faster Decisions Without More Headcount

The biggest change shows up in your queue. Clean requests clear automatically, so clinical reviewers focus on the cases that need them. Deadlines become visible to everyone, and alerts arrive while there's still time to act.

Consistency improves too. Every request runs through the same criteria, and every decision carries a clear reason and a complete record.

Reporting stops being a scramble. Public metrics and internal audit reports pull from the same unified data, so they're ready whenever you need them.

And when January 2027 arrives, the required APIs are already in place and connected to the systems you run on.

Ready to Meet Every CMS-0057-F Deadline?

Prior authorization volume isn't slowing down, and neither are the regulations. Let's look at your current prior authorization workflow and talk through how fast a tailored solution can go live.