The HealthRules Solution Suite
HealthRules® for Home and Host Health Plans
Core Administrative Processing System (CAPS)
Home and Host plans have led the healthcare industry since 1929. Counting 1 in 3 Americans as members, they have a significant opportunity to drive transformation. HealthEdge® solutions enable our clients to react swiftly to regulatory shifts and market changes, support new business models, and offer business insights that can lower costs and improve outcomes, efficiency and transparency.
HealthRules Payer offers integrated, real-time capabilities that support all core administrative operations, ensuring that all home and host functionality works seamlessly. Plus, using the highest standard of hosting services enables you to reduce the time to go-live, achieve successful implementation with lower risk, and make a smooth transition to HealthRules Payer.
Learn MoreFeatures
Seamless Integration
HealthRules Payer has built-in capabilities to support all aspects of the home and host program. These solutions reduce complexity and eliminate unnecessary duplication of provider data.
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APIC3 Service
The home solution utilizes APIC3, a more efficient and streamlined service for Pricing and Disposition Format build.
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Submission Format Configuration
The host solution allows configuration of the Submission Format data elements, enabling faster implementation of changes.
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ITS Access
By providing hosting services and shared solutions for home and host health plans, HealthRules accesses the software components and databases of Inter-Plan Teleprocessing Services (ITS) via a shared platform and utilizes batch file transfers or message-oriented middleware for communications.
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Private Connection Integration
HealthRules Payer is integrated with your home and host health plan through a private connection. This enables customers to access the standard, reliable services offered by the hosting services while ensuring faster implementation of claims processing and changes.
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Association-Mandated Web Application Integration
HealthRules Payer is also fully integrated with an association-mandated web application, giving home and host customers the convenience of sending and receiving adjustment messages directly from within HealthRules Payer.
Learn MoreRequest a Demo
Get the agility you need to freely update validation policies, modify fee schedules, restructure benefit plans and launch new lines of business.
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What Sets Us Apart
Resiliency to Change
With HealthRules Payer, you can confidently embrace change, responding to health and environmental events, creating new or expanding lines of business, all while reacting to and remaining compliant with regulatory requirements.
Learn MoreOperational Efficiency
HealthRules Payer was built to support not only how health insurers operate today but with flexibility and scalability to handle what the future brings, enabling customers to reach unparalleled levels of operational efficiency in the face of shifting market dynamics. HealthEdge customers regularly achieve auto-adjudication rates over 90% with at least 99% accuracy while automation helps eliminate waste and maximize resources.
Learn MoreConfigure the Business
The HealthRules Payer platform allows business analysts to do rapid configuration and make changes with ease and confidence, and offers virtually unlimited flexibility in defining new benefit plans, provider contracts, and other core business processes.
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HealthRules Payer offers controlled and comprehensive modeling of new product designs and provider pricing methodologies, and delivers unparalleled support for new healthcare business models
Learn MoreIntegration Comes Easy
HealthRules easily integrates with other best-of-breed systems in real time via APIs and integration technologies for more cost-effective, low-risk maintenance of the IT ecosystem.
Learn MoreActionable Insights
HealthRules Payer can combine with analytics to provide insights that improve patient outcomes, lower costs, and enable transparency inside and outside the health plan. Leveraging actionable, real-time insights improves patient outcomes, lowers costs, and enables transparency inside and outside of the health plan.
Learn MoreReimagined Upgrades
HealthRules Payer is reimagining core administrative software upgrades by reducing the operational challenges our customers face in taking regular upgrades by minimizing external costs. The resulting advantage is the overall benefit health plans gain from the innovation delivered in new releases. HealthRules for home and host plans is certified for the bi-annual releases, ensuring you remain in compliance with Association programs. New releases are available in advance to allow time for global certification testing.
Learn MoreCare-Payer Integration
HealthRules Payer is even more powerful when combined with GuidingCare®. Our unique Care-Payer Data Exchange solution provides the API-based integration that enables the continuous management of member care and core administrative processes.
Care-Payer provides a range of vital capabilities, including:
- Standardized core data delivery from HealthRules Payer to GuidingCare
- Authorization entry workflow improvement, including single-case agreement and referral category enhancement
- Near-real-time authorization delivery from GuidingCare to HealthRules Payer
Most notably, Care-Payer includes Benefit Predictor integration. This unique feature enables GuidingCare users to quickly and easily answer complex benefit questions prospectively from members and providers. This Benefit Predictor integration is incorporated into several key workflows, giving Utilization Management staff and care managers unparalleled access to near-real-time benefits information.
Care-Payer Data Exchange delivers significant benefits to your organization, including:
- Smooth implementation through HealthEdge expertise and standardized processes
- Synchronized data sets between HealthRules Payer and GuidingCare
- New levels of operational efficiency in authorization entry and medical management
- Improved payment integrity
- Certified data exchange
Payer-Source Integration
The integration between HealthRules Payer and Source creates a new level of operational efficiency and accuracy in claims pricing and editing. With the continuous management of payment integrity and core administrative processes between platforms, the Payer-Source integration enables:
- A single source of truth
- Increased accuracy
- Organization-wide IT lift
- Improved payment integrity
- Streamlined support model
The increased transparency gained from the Payer-Source integration improves payer-provider relations and member satisfaction.
LEARN MOREThe HealthRules Solution Suite
HealthRules Payer
HealthRules Payer provides transformational capabilities to health plans of all types and sizes with features that align with your business processes and functional areas.
EXPLORE PRODUCTHealthRules Answers
Our HealthRules Answers business intelligence solution transforms the way you see and use data in real time, helping to reduce costs, identify market opportunities, validate new product offerings, and support next-generation business models.
EXPLORE PRODUCTHealthRules Connector
HealthRules Connector is a robust integration layer that links HealthRules seamlessly with other systems, partner networks, and exchanges so you can share critical healthcare information quickly, easily and securely.
EXPLORE PRODUCTAdditional Offerings
HealthRules Promote
Our Configuration and Promotion application enables your organization to benefit from increased automation, greater accuracy, a simplified process and lower costs.
EXPLORE PRODUCTMachine Readable Files
The HealthRules Machine Readable Files Suite 3.x is a cloud-deployed SaaS application that improves health plans’ processes for publishing Machine-Readable Files (MRF) of their negotiated rates and allowed amounts, making meeting regulatory requirements easier, faster, and more accurate than ever.
Watch The VideoProvider Data Management
HealthEdge Provider Data Management creates a single source of truth for provider data. Natively integrated with Core Administrative Processing System, Provider Data Management streamlines ingestion and enrichment using a Generitive AI-powered framework and distributes cleansed data through a configurable, event-based, realtime API architecture. This enables real-time accurate data to flow across the HealthEdge solution suite and the broader heath plan ecosystem.
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