# Health Plan and Payer Document Automation for Salesforce | CloudFiles

> Health plan document automation in Salesforce Health Cloud: faxed prior authorization intake, completeness checks, determination letters and appeal datarooms.

*Health plan document automation*

## CloudFiles for *health plans and payers*

Prior authorization forms, clinical records and appeal filings reach health plans as faxes and PDFs, apart from their care request. CloudFiles turns each faxed request, saved as a PDF, into a care request and files every document behind it.

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*Utilization management documents, before and after*

## From a faxed request to a *documented* determination

Health Cloud tracks every care request from intake to a decision. CloudFiles handles the faxes, clinical records and letters that move each of those requests along the way.

### The manual way

- Intake coordinators retype the member, requesting practitioner and each requested service from every faxed prior authorization form into a care request. Urgent requests can wait behind routine ones, and a refiled fax can become a second request.
- Nurse reviewers open each clinical document a provider sends to work out whether the care request is complete. A request found short only at review can move to more information requested, and the decision then waits on the provider.
- Before a peer to peer call, utilization staff gather the clinical records for the medical director from the case files one at a time. A note missed in that search can leave the reviewer without evidence the provider plans to cite.
- Utilization management staff draft each determination letter by hand, carrying the decision, reason and dates over from the care request. The finished letter then goes to the provider as a fax or an email attachment, one more loose copy to track.
- Appeals coordinators send the decision file in one email and ask for the appeal form and new records in another. Members and representatives can return pages in pieces, and a missing appointment of representative form can stall the appeal.

### The CloudFiles way

- Each faxed prior authorization form, saved as a PDF, becomes a care request with an item for every requested service. The priority on the form is filled in, so urgent requests stand out. Coordinators start each review from a record that is already filled in.
- Every care request shows whether its clinical file is complete while documents are still arriving. Each scanned or digital PDF is classified against the list for its request type. A flow then sets the document attachment status to complete or incomplete.
- The medical director opens one complete packet before every peer to peer call with the provider. When the case sub-status becomes peer to peer review scheduled, the request's clinical records are merged in order into one PDF in its folder.
- Each determination letter is built from the care request the moment its case sub-status becomes approved, denied or partially approved. The provider receives one secure link to the PDF, emailed by a flow, in place of a faxed copy of the letter.
- Each appeal care request gets its own dataroom, and a flow emails its link to the member or their representative. The decision file is shared there, and the representative form's arrival stamps its received date on the appeal record.

*Health plan use cases in Salesforce*

## Every review *documented* from intake to appeal

Beyond utilization management, health plans run CloudFiles on network applications, member mailings and appeal files in Health Cloud.

- **Clinical answers for nurse reviewers** — CloudFiles answers set questions about the clinical records behind a care request, such as prior treatments tried and recent test results. Each answer lands in a field before the nurse review begins.
  - The process document using AI flow action prepares each clinical record once, as soon as it reaches the request's folder
  - A second flow, started by the document processed event, runs query document with the plan's own questions
  - The nurse reviewer sees each answer beside its source record before making the review decision
- **Member ID cards and welcome letters in one run** — CloudFiles generates an ID card and a welcome letter for every new member plan in a list. Each document takes the member's numbers and payer from its record, and every PDF lands in that member's folder.
  - The generate document (batch) flow action runs on the list of new member plans and builds one document per record
  - A Word template positions the member and group numbers exactly where the plan's card design expects them
  - The fulfillment team picks up each finished PDF from the member's folder when the print run is ready to go
- **Network application documents filed by type** — CloudFiles sorts the licenses, malpractice certificate and W-9 a provider sends with an individual application into matching sub-folders. The network team finds each credential without opening every file in turn.
  - The process document using AI flow action prepares each upload, and query document names its document type
  - The move resource flow action files each document into the license, insurance or tax sub-folder of the application
  - Network staff open the application and find each document already waiting in the sub-folder for its type
- **Grievance and complaint letters routed by type** — CloudFiles decides whether each member letter is an appeal, a grievance or a complaint. A flow then files the letter in the folder for that care request type, so each coordinator works only their own team's letters.
  - Each letter that reaches the member's intake folder is prepared by process document using AI, then asked about its type
  - The move resource flow action files the letter under the appeal, grievance or complaint folder for that member
  - The same flow writes the letter type to the member's person account, so coordinators see it before opening any file
- **Summary of benefits tagged by plan type** — CloudFiles writes each purchaser plan's plan type and name onto its summary of benefits file in SharePoint. Member services staff can then filter benefit documents by plan type without opening Salesforce first.
  - Each summary of benefits is uploaded to the purchaser plan's folder straight from its record page in Salesforce
  - The set resource property flow action writes plan type and plan name to SharePoint columns by their API names
  - Staff working in SharePoint filter the library by plan type, such as Medicare or Medicaid, and open the right file
- **Appeal files added to the dataroom** — CloudFiles lets an appeal reviewer tick supporting files in the CloudFiles widget and add them all to the appeal's dataroom with one button. Nothing is downloaded and uploaded again.
  - A widget list action on the appeal care request runs a flow on whichever files the reviewer has ticked
  - The flow calls the add to dataroom flow action for each ticked file, placing it beside the appeal's earlier filings
  - The button menu appears only once a file is ticked, so the widget stays clear while reviewers browse the folder

*Document types*

## Key documents we handle for *health plans and payers*

These are the documents a health plan's utilization, appeals and network teams handle most, each kept on its own Health Cloud record.

- **Prior authorization requests** — Forms received by fax or upload and saved as PDFs, asking the plan to approve a service or drug. Each one opens a care request that lists every service as its own line.
- **Clinical records** — Visit notes, lab results and imaging a provider submits behind a care request, each one counted toward that request type's required set.
- **Determination letters** — The plan's written decision on a care request, built from the record once the case sub-status shows the outcome, then linked to the provider.
- **Appeals and grievances** — Member and provider filings that contest a decision or raise a complaint, each recorded in Health Cloud as a care request of its own type.
- **Provider applications** — Licenses, malpractice certificates and W-9 forms a provider submits with an individual application to join the health plan's provider network.
- **Member ID cards** — Each member's card, printed with the identifiers held on the member plan record, produced in a batch and saved to that member's folder.

*Security & compliance*

## Stay industry compliant

CloudFiles is independently audited for SOC 2 Type II, certified to ISO 27001, and compliant with HIPAA and GDPR. Data residency is supported in the US, EU, UK and AU. Your files stay in your own storage. CloudFiles never re-hosts them, and they are not used to train our AI models.

Certifications: SOC 2 (Type II), HIPAA (Compliant), ISO 27001 (Certified), GDPR (Compliant)

[Security overview](/security)

## Frequently asked questions

**Q: Where does CloudFiles fit in utilization management on Health Cloud?**
CloudFiles works on the care request, its linked case and the care request extension that Health Cloud uses for utilization management. As clinical documents are classified, CloudFiles sets the document attachment status. When the case sub-status changes to an outcome, CloudFiles builds the determination letter.

**Q: Can CloudFiles build peer to peer review packets for medical directors?**
Yes. CloudFiles merges a care request's clinical records into one PDF when its case sub-status is set to peer to peer review scheduled. Health Cloud keeps that sub-status on the care request extension. The packet holds whole files in the sequence the flow sets, so the medical director sees the case in order.

**Q: Can CloudFiles answer nurse review questions from a care request's clinical records?**
Yes. CloudFiles asks each clinical record the plan's own questions, such as which treatments were tried, and writes the answers to care request fields. Health Cloud lists the nurses assigned to a request as care request reviewers. A flow can alert those reviewers as soon as the answers are on the request.

**Q: How does CloudFiles handle health plan appeals in Health Cloud?**
CloudFiles opens one dataroom per appeal, where the member or representative sees the decision file and uploads new records. Health Cloud records appeals, complaints and grievances as care requests, with fields such as appeal reason and reference authorization number. Each new upload lands beside the appeal's earlier filings.

**Q: Can CloudFiles sort provider network application documents in Health Cloud?**
Yes. CloudFiles files each license, malpractice certificate and tax form from a provider into the individual application's sub-folder for that document type. Health Cloud tracks each individual application from submitted to in review. A flow can move the application to in review once every required document type has arrived.

**Q: Can CloudFiles produce member ID cards from Health Cloud member plans?**
Yes. CloudFiles produces one member ID card and one welcome letter per member plan on a list, in a single batch run. Health Cloud keeps the payer, group number and member number on each member plan. Each card follows the newest version of the template, so a design change reaches the next run.

## Book your *personalized* demo

Bring a faxed prior authorization form with member details removed, and watch it become a care request in Salesforce Health Cloud.

[Book a demo](https://meet.cloudfiles.io/salesforce?utm_content=sf-industries-healthcare-health-plans-and-payers-footer)