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Introducing Salesforce Health Cloud for insurance

by Paul B. Stevenson, MPA, CPA

Salesforce is not new to health plan providers, who have been using Salesforce Sales Cloud to operate group and Medicare sales teams for years. More recently, Salesforce Service Cloud has been deployed by health plan call centers to improve customer service, especially for Medicare health plans seeking the elusive CMS five-star rating.

The Salesforce Health Cloud has been available since May 2016, but its focus on healthcare providers has limited its use in the health insurance industry. Now, that is about to change, as Salesforce Health Cloud for Insurance includes a payer data model to serve the needs of health plans. Using the new data model, health plans can integrate their claims system and HL-7 Electronic Medical Record data directly into Salesforce to support member services operations.

The new data model provides data objects for a host of insurance and utilization management data objects to work in concert with the core functions of Health Cloud that give a 360-degree view of the patient using the Care Team and Care Timeline features.

Simplus can help health plan providers who are seeking to improve their health plan operations. We can evaluate several use cases including group and Medicare sales, call center automation, and utilization management to determine if Salesforce Health Cloud can give your health plan a strategic advantage. Increased sales, improved customer and provider satisfaction scores, and reduced medical expenses are the goals of our implementation services.


Features of Salesforce Health Cloud for insurance

The new features of Health Cloud for Insurance include a payer-specific data model with support for common data objects that health plans use to manage their claims payment systems. Salesforce Health Cloud can be integrated with one or more payment systems, which is very powerful for health plans which operate multiple payment systems due to mergers or acquisitions. Using Mulesoft, Informatica, or other integration tools, various claims systems can be merged virtually into Salesforce Health Cloud for insurance, allowing call center agents to handle all members with a single interface.

The new common interface can handle a wide variety of common use cases for group and member service inquiries, including:

Payer: Support the specific insurance company at risk for member benefits.

Employer: Support the employer and associated plans purchased from the payer.

Employer Plan: Represent the various insurance plans offered to employees.

Employer Plan Benefits and Detail Line Items: Provide a hierarchy to manage benefits covered under various insurance plans.

Member: Support for employees and dependents, including households, that are covered by insurance plans. Can also be used with Medicare, Medicaid, or Accountable Care Act plans for individual and family coverage plans.

Covered Benefits and Detail Line Items: Hierarchical support for covered benefits with detail records for easy access to handle higher level coverage questions while keeping more specific information at the agent’s fingertips.

Care Pre-Authorization: Support for care authorizations with master detail records for easy access to specific detailed line item data.

Claims Data: Claims data is not integrated directly into the new data model. Instead, we use virtual connections with the claims system(s) or a data warehouse to provide virtual integration using Salesforce Connect.


Security with Salesforce Health Cloud for insurance

These data objects can support health insurance operations for the entire member lifecycle starting from group or individual sales using Salesforce Sales Cloud to capture leads and close opportunities. Group sales can be expedited using Salesforce CPQ to handle the complicated health insurance quoting and underwriting processes. Once enrolled, members can receive five-star service using Salesforce Health Cloud Service Console and Salesforce Communities to make secure interaction with your health plan according to the member’s preferences.

All of the Salesforce Health Cloud interactions are secured using Salesforce Shield, which provides state-of-the-art HIPAA security with platform encryption, event monitoring, and field audit trail.


What Simplus does for you

Simplus can provide you with the expertise to design and implement your vision of the best-of-breed health plan. Using Executive Visioning, End User Journey Mapping, and a Technology Assessment, we will build a roadmap that you can implement at your organization’s speed.

Using data integration tools to interact with your health plan’s system(s) of record, you won’t need to make wholesale information systems changes that are extremely risky and costly. Instead, using Salesforce Health Cloud as a ‘success blanket,’ you can cover those mission-critical systems with a flexible, responsive interface to enhance worker and member experience.

For more information, contact Paul Stevenson at [email protected]


Paul is a Principal CRM Strategist here at Simplus. An expert with deep CRM experience in healthcare, telecom, distribution, and financial segments, Paul is a consultant who drives CRM innovations to clear a path for growth in revenue and operational efficiency. He has hands-on experience in developing, marketing and selling CRM Apps and is a proven project leader with skills to lead CRM integrations with payer, provider, telecom, and proprietary operational and financial information systems.

[email protected]

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