Health-Cloud-Accredited-Professional Practice Test Questions

Explanation:

Expression Set Templates are the prebuilt feature that the payer should leverage to implement predefined rules for its prior authorization request review process. Expression Set Templates are reusable sets of expressions that can be used to evaluate business logic and trigger actions based on the results.

Explanation:

According to the Health Cloud Implementation Guide, the recommended best practice for modeling members in Health Cloud for a payer service cloud org that uses accounts and contacts to model health insurance members is to model them as person accounts, whether they are using Health Cloud capabilities or not. Person accounts are a type of account that combines account and contact information in a single record. They are suitable for representing individual consumers in healthcare and life sciences. Using person accounts for all members can simplify data management and avoid data duplication. Only groups needing Health Cloud capabilities need to use person accounts is not a recommended best practice, as it can create inconsistency and complexity in data modeling. Account record types for existing members can remain as-is is not a recommended best practice, as it can limit the functionality and integration of Health Cloud features. Using the individual model with Health Cloud is not a valid option, as the individual model is not supported by Health Cloud.

Explanation:

According to the Salesforce documentation1, the following types of electronic health record data transmitted via HL7 can be stored in Salesforce objects:

Observation Results (ORU): ORU messages contain clinical observations and results, such as lab tests, vital signs, or imaging reports. ORU messages can be stored in the DiagnosticReport object in Health Cloud1.

Admission, Discharge, Transfer Data (ADT): ADT messages contain information about patient admissions, discharges, transfers, or updates, such as demographics, insurance, or diagnosis. ADT messages can be stored in the EhrPatient object in Health Cloud1.

Clinical Document Architecture (CDA): CDA is a standard for exchanging clinical documents, such as discharge summaries, progress notes, or referrals. CDA documents can be stored in the Document object in Health Cloud1.

Explanation:

✅ B. Designing Care Requests to seek authorization from a health plan for drugs, services, and admissions – Utilization Management (UM) often involves Care Requests (or Prior Authorization Requests) to ensure medical necessity before approving treatments, procedures, or medications. This aligns with the payer’s need to review care appropriateness case-by-case.

✅ D. Considering the Request Review Types; Prior Authorization Review, Concurrent Review, and Retrospective Review – These are the three core UM review types:
1. Prior Authorization: Pre-approval for care (e.g., surgeries).
2. Concurrent Review: Ongoing care reviews (e.g., hospital stays).
3. Retrospective Review: Post-care audits (e.g., claims reconciliation).
Discussing these ensures the payer can evaluate care at all stages.

Why Not the Others?
❌ A. Designing Next Best Action and Recommendations – While useful for care management teams, this focuses on clinical guidance (e.g., care plans) rather than payer-side utilization control.
❌ C. Considering the number of intake agents – This is an operational/technical consideration (user setup), not a UM process for care appropriateness reviews.

Explanation:

FHIRR4 is the industry data standard that a consultant should use with Health Cloud. FHIRR4 stands for Fast Healthcare Interoperability Resources Release 4, and it is a standard for exchanging healthcare information electronically. FHIRR4 enables interoperability between different systems and applications, and supports a variety of use cases, such as clinical, administrative, and financial.

Explanation:

According to the Salesforce documentation2, the following standard objects are used in the workflow to manage utilization data:

Care Request Plan: A care request plan is an object that stores information about the plan of care for a member. It includes details such as the diagnosis, the service type, the start and end dates, and the status of the plan2.

Care Authorization: A care authorization is an object that stores information about the approval or denial of a service or payment by a payer. It includes details such as the authorization number, the decision date, the decision reason, and the status of the authorization2.

Care Request: A care request is an object that stores information about the request for a service or payment by a provider or a member. It includes details such as the request type, the request date, the priority, and the status of the request2.

Explanation:

Mask is a Salesforce product that helps you anonymize sensitive data in production copy sandboxes to ensure privacy, compliance, and regulatory requirements are met3. Mask replaces sensitive data with fictitious yet realistic data that preserves the characteristics of the original data. It also prevents unauthorized access to sensitive data by masking it before it is copied to a sandbox3.

Explanation:

✅ A. Healthcare Provider Specialty – Tracks the specialties (e.g., Cardiology, Pediatrics) associated with a healthcare provider.
✅ D. Healthcare Practitioner Facility – Records the facilities (e.g., hospitals, clinics) where a provider practices.
✅ E. Board Certification – Stores certification details (e.g., board names, expiration dates) for providers.

Why Not the Others?
❌ B. Provider Education – While important, this is not a standard out-of-the-box Health Cloud object. Education details would typically be captured in custom fields or related objects.
❌ C. Practitioner Tier – This is not a native Health Cloud object. Tiered provider networks (e.g., Tier 1, Tier 2) would require custom configuration.

Explanation:

Risk scores are recalculated only for patients that are affiliated with a Care Program © is the most likely reason why the recalculation score for the patient is not displaying. CMS risk scores can be recalculated in Health Cloud (A), so this is not a reason for the score not displaying. CMS risk scores can be recalculated using both third party APIs and Salesforce APIs (B), so this is not a reason for the score not displaying. Risk scores can be calculated using both the CMS recalculation API and other methods (D), so this is not a reason for the score not displaying.

Explanation:

Concurrent review is a type of care request review that ensures that a member is getting the right care in a timely and cost-effective way. It involves reviewing the medical necessity and appropriateness of an ongoing service or admission3. Disposition review, care review, preauthorization review, and retrospective review are not the correct terms for this type of review.