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HealthEdge Source™ earned the 2026 Best in KLAS Awards: Software and Services as the leader in “Pre-Payment Accuracy & Integrity Solutions (Payer)”—with an overall score 8% higher than its competitors. HealthEdge Source was also the only solution to earn a higher overall score in 2026 than the previous year. This achievement not only highlights the HealthEdge® commitment to excellence, but our customers’ recognition of the ongoing innovation and partnership we deliver. 

“The Best in KLAS awards recognize the vendors who consistently deliver excellence through partnership with healthcare organizations. Winning this award means customers trust you to help them succeed in our rapidly changing healthcare landscape.”
-Adam Gale, CEO, KLAS Research 

Across the healthcare industry, health plans are moving from traditional “pay-and-chase” models to making prospective payments. Solutions like HealthEdge Source help ensure payers are accurately processing claims the first time to improve cost avoidance and reduce downstream waste. 

What Does it Mean to Earn “Best in KLAS”?

KLAS is a trusted third-party research firm dedicated to improving healthcare by gathering, analyzing, and sharing insights based on direct feedback from thousands of healthcare professionals.  

Unlike other industry recognitions, the annual Best in KLAS reports are not based on marketing claims or theoretical performance. Instead, rankings are determined based on testimonials from anonymous, direct feedback from actual health plan customers. For payers, these rankings highlight vendor software solutions that excel in helping healthcare organizations ensure accurate payment and reimbursement.  

In the 2026 report, HealthEdge Source outperformed competitors across several critical categories: 

These scores reflect a platform that is not only robust in its technical capabilities but also passionate about empowering health plan operations by being a true partner. 

Why the Best in KLAS Designation Matters

For health plan leaders, selecting a payment integrity solution is a strategic decision with long-term financial and operational implications. The Best in KLAS designation offers validation that HealthEdge Source delivers on its promises to streamline payment integrity workflows, reduce rework, and process claims correctly the first time. 

One statistic from the report stands out above the rest: when asked if they would adopt HealthEdge Source again and include it in their long-term plans, 100% of customers said “yes”. 

This perfect loyalty score affirms the long-term commitment HealthEdge has made to helping payers optimize pre-payment integrity. It demonstrates that the platform is designed and supported by a team with the common goal to improve healthcare for everyone. 

Real Results Through a Unified Platform

Why do health plans choose to partner with HealthEdge Source? The answer lies in the shift from reactive, disjointed tools to a proactive, integrated ecosystem. While many traditional black-box payment integrity solutions offer limited visibility for health plans to address root-cause issues, HealthEdge Source provides an open book approach that empowers health plans to make edits in-house, proactively address errors, and reduce operational waste. 

The unique platform architecture provides health plans with control, transparency, and future-ready functionality, addressing the core challenges of modern claims processing. 

Configurable Edits and Rules

The platform does not force a “one-size-fits-all” approach. Instead, it offers advanced, configurable editing tools that can be tailored to each health plan’s specific reimbursement models and clinical policies. This helps ensure precision and compliance with internal and external standards. 

Integrated Payment Integrity

Efficiency demands connectivity. HealthEdge Source seamlessly connects with core administrative systems, pricing engines, and external data sources for a unified and transparent workflow. This approach redefines payment integrity by providing platform-level access rather than isolated point solutions. 

Actionable Intelligence

Data is only valuable when it drives informed decision-making. The platform provides intuitive dashboards and comprehensive audit trails, offering advanced analytics and radical transparency that support compliance and strategic decision-making. 

Keep Your Health Plan Up to Date

To help payers meet market needs, digital platforms need to operate with the latest intelligence and guidelines. HealthEdge Source delivers platform-wide updates on a 2-week cycle to help maintain accuracy and flexibility. Plus, the Retroactive Change Manager tool improves transparency throughout the claims management process by automatically flagging reconcilable claims, scheduling reviews, and reducing the need for manual intervention. 

Partner with the Market Leader in Payment Integrity

“Health plans need payment integrity that delivers accuracy, insight, and control at scale. Being named Best in KLAS validates HealthEdge Source as the modern standard for payment integrity—and we expect to continue raising the bar for the industry.” 
-Ryan Mooney, Chief Product Officer at HealthEdge 

When they choose HealthEdge Source, health plans gain a partner that is dedicated to delivering a transparent, accurate, and open-book approach to payment integrity. From being the first solution in the market to include pricing and editing in a single module to integrating AI-powered features, the solution helps payers operate more efficiently and support their members more effectively. 

To see a breakdown of the data and learn more about how HealthEdge Source can transform payment integrity, download the data sheet. 

Industry pressures like regulatory complexity and the shift toward value-based care demand that health plans take an integrated, strategic approach to care management. Whether payers are evaluating a new care management platform or seeking greater value from an existing solution, precision and a commitment to innovation are essential for success.

HealthEdge GuidingCare® offers an advanced, integrated care management solution that delivers measurable outcomes for care teams, administrators, and members. The GuidingCare platform delivers a robust foundation that enables health plans to maintain core care workflows while improving key areas such as Medical Loss Ratio (MLR) and holistic care delivery. By fully utilizing GuidingCare’s built-in modules, healthcare organizations can eliminate data silos, enhance member engagement, and unlock actionable insights on clinical and financial performance.

Unlock Efficiency by Combining Fragmented Solutions

Fragmented solutions can impede agility and elevate costs. When functions like utilization management and population health analytics exist in isolation, care teams are forced to reconcile disparate data sources, resulting in inefficiencies and delayed interventions. But platforms with built-in integration capabilities can provide a unified view of each member’s journey and enable more personalized outreach.

GuidingCare was built as a modular, fully interoperable digital ecosystem. Whether payers are considering the platform for the first time or expanding their current usage, there are opportunities to enable seamless data flow across care management, digital engagement, analytics, and compliance.

Translating Data into Action: GuidingSigns Analytics

For new adopters, GuidingSigns Analytics provides predictive power that goes beyond conventional reporting to transform retrospective claims data into forward-looking, risk-based intelligence. Existing users can drive even greater ROI by configuring customizable risk models and integrating Social Determinants of Health (SDOH) data to help prioritize member interventions.

GuidingCare gives care teams access to real-time, comprehensive member profiles that inform targeted outreach and move away from reactive risk mitigation to proactive cost avoidance. The platform’s flexibility supports rapid response to emerging risk and optimizes care team productivity, directly impacting key areas like MLR and member outcomes.

Closing the Engagement Gap with Digital Tools

Member engagement is foundational to any successful care management strategy. GuidingCare’s digital member engagement module supports HIPAA-compliant, streamlined, bidirectional communication between care teams and members. For health plans new to GuidingCare, this means integrated engagement from day one. For current customers, activating digital engagement enables real-time data sharing, symptom tracking, educational interventions, and feedback loops that inform clinical interventions, build member trust, and improve satisfaction.

Operational Agility and Regulatory Excellence

The move toward modular, integrated care management is not only about outcomes but achieving operational resilience and compliance at scale. GuidingCare’s Appeals & Grievances and Utilization Management modules are engineered for regulatory agility, automating complex processes and mitigating compliance risks without additional administrative overhead.

By consolidating disparate point solutions, health plans can benefit from streamlined data management, reduced IT burden, and enhanced agility to respond to market and regulatory change.

Real-World Member Journey: Bringing Whole-Person Care to Life

Imagine a member diagnosed with congestive heart failure who has recently been discharged from the hospital. Using GuidingCare, the care manager begins by accessing a unified, longitudinal member profile that aggregates clinical history, pharmacy data, SDOH factors, and recent hospital events.

The care manager leverages GuidingSigns Analytics to assess the member’s risk for readmission, identifying social or behavioral health barriers that might impact recovery. Through configurable business rules, the platform recommends an evidence-based, individualized care plan and initiates an automated transition-of-care workflow.

Leveraging the digital engagement module, the care manager quickly enrolls the member in daily symptom and medication adherence tracking. When the member logs new symptoms through the mobile app, this data is instantly available to the care manager, who receives a real-time alert. The care manager responds by adjusting the care plan, coordinating with primary care and specialists, and scheduling necessary virtual or home visits.

Throughout the journey, the Utilization Management module allows the coordination of authorizations and services while the Appeals & Grievances module ensures that member issues are documented and resolved with full transparency. The entire process—from risk assessment to multi-channel communication and regulatory compliance—is streamlined within the integrated platform, empowering the care manager to support better outcomes, reduce avoidable readmissions, and foster meaningful member engagement.

Your Partner for Transformation

Healthcare continues to evolve, driven by innovation, regulation, and member needs. HealthEdge® is committed to advancing care management through solutions that anticipate tomorrow’s challenges while delivering measurable ROI.

Whether you’re ready to embark on your care management transformation or seeking to amplify the impact of your existing platform, GuidingCare delivers a future-proof ecosystem for comprehensive, member-centric care.

Discover what GuidingCare can do for your organization. Read the 2025 IDC MarketScape: U.S. Value-Based Healthcare Analytics Vendor Assessment to see how our unified digital ecosystem delivers operational, clinical, and financial results.

Care teams, product managers, and operations leaders across healthcare live inside documents: contracts, benefit summaries, clinical policies, internal runbooks, and email threads. These artifacts carry critical business logic, yet they are largely unstructured and scattered across repositories. Finding a precise answer often means opening multiple PDFs, searching manually, and asking colleagues to “remember where that clause was.” It’s slow, brittle, and hard to scale.

To address this, our AI Platform team built a retrieval-augmented generation (RAG) layer that uses AI agents to reason over unstructured content at scale. Instead of treating each content type as a custom integration, we now empower customers to use a single platform that can ingest, enrich, index, and serve knowledge from contracts, product documentation, release notes, and more.

Healthcare Runs on Documents—But Finding Answers Is Often a Big Challenge

Our starting point was a simple but pervasive problem: “I know this answer exists somewhere in a document, but I can’t find it quickly.” We heard from our customers that this is one of the most common statements across all types of teams, including those responsible for contracts, pricing, implementations, and customer communication.

We wanted a solution that was:

1. Unstructured first – Worked across unstructured content without requiring any schema upfront.
2. Safe for healthcare – Could be safely used in regulated healthcare contexts.
3. Composable – Was reusable across multiple products and workflows rather than built as a one-off feature.

The first wave of use cases includes contract, policy, and product documentation question-and-answer resources for internal users.

A Healthcare-Ready AI Platform for Unstructured Content

Our new AI-powered RAG capability is designed as a platform service, not a single UI, and is part of a broader vision for modern, intelligent health plan technology. At its core, it provides a small, opinionated set of features that product teams can compose into their own experiences:

Natural language Q&A over documents

Users pick a corpus (for example, “Client X Contracts 2025” or “Product Release Notes”) and ask natural language questions. Responses are concise, grounded, and come with citations to the underlying pages or paragraphs.

Context-aware chat

A conversational interface keeps context across turns, allowing users to drill deeper (“Show me where you found that” or “Explain the contract terms to me”).

Traceability and safety controls

Every answer includes citations, and audit logs are stored. This makes it easier for users to validate responses and for teams to adopt the system in workflows that require human review.

Because the platform is API-driven, feature teams can embed these capabilities in different places: internal tools, client-facing portals, or operational dashboards—all backed by the same RAG layer.

Under the Hood: How HealthEdge’s RAG Platform Works

The architecture follows a classic RAG pattern designed for multi-tenant use.

Ingestion and enrichment: Content lands in our blob storage module, either through bulk loads or product-specific pipelines. An event-driven ingestion service listens for new or updated blobs and orchestrates:

• Extracting text from documents and scanned content.
• Chunking content into overlapping segments with a fixed character length, so long documents can be searched efficiently while keeping enough local context for the model to answer questions accurately.
• Enriching with metadata (tenant, application, document name).
• Generating vector embeddings for each chunk—numerical representations of the text that capture its meaning—so we can perform semantic search, not just keyword matching.

The enriched chunks and metadata are then pushed into AI search indexes—specialized data structures optimized for search, which store both full-text and vector representations. Per-tenant isolation is handled via index boundaries and metadata filters, ensuring that each client’s content remains logically and operationally separate.

Retrieval and generation: For each user query, the retrieval service:

• Resolves the tenant and corpus to the correct index scope.
• Returns a compact set of passages with metadata and citation handles.
• Invokes an AI agent with a prompt that includes the most relevant passages, conversation history, and system instructions focused on citation, faithfulness, and tone.

All calls travel through guardrails, including content safety and prompt injection checks, and are fully instrumented with logging and observability. Because product teams integrate with the RAG platform via a stable API, we can change models, tweak prompts, or introduce new retrieval strategies behind the scenes without affecting downstream consumers.

Early Wins: Faster Answers, Safer Decisions, and Shared Infrastructure

While still early in rollout, we are already seeing tangible benefits in pilot teams:

• Time-to-answer – Routine contract questions that previously took several minutes now typically get resolved in a single query and follow-up.
• Consistent, auditable responses – Citations and logs provide a clear trail from an answer back to specific clauses.
• Reusable building block – Instead of building bespoke Q&A for each project, product teams can plug into a single RAG service with configuration for their domain.

Equally important, teams are no longer building parallel, one-off RAG implementations. They can focus on product-specific UX while the platform team centrally evolves retrieval quality, observability, and guardrails.

Turning Institutional Knowledge into Actionable Answers

Unstructured documents are where much of our institutional knowledge lives, but they have historically been hard to search, compare, and operationalize. By building a RAG capability, we’ve created a common layer that can turn those documents into actionable, explainable answers.

As we expand, we’re focusing on making answers even more grounded and consistent, strengthening evaluation of retrieval and response quality, deeper integration into existing workflows, and support for additional content types. But the core idea remains simple: meet users where they already work.

To follow HealthEdge’s AI strategy in greater detail, visit the Resources section of our website, www.healthedge.com.

Contact HealthEdge to learn how our AI solutions can streamline your provider data management operations.

As health plans face mounting cost pressures and an increasingly complex regulatory landscape, one thing has become clear: incremental change is no longer enough. Today’s health plan environment demands transformational solutions, and a growing body of evidence points to the combined power of technology and Business Process as a Service (BPaaS) as the most effective path forward.

The HealthEdge® 2026 Healthcare Payer Survey Report reveals just how urgent the moment has become. Cost containment remains the number one challenge for the second year in a row, while regulatory compliance has surged near the top of the list, driven in part by sweeping changes introduced through the One Big Beautiful Bill Act (OBBBA).

The Market Shift: Cost and Compliance Are Forcing a Strategic Reset

With healthcare costs projected to reach $7.7 trillion by 2032, outpacing both inflation and wage growth, health plans are under extreme pressure to modernize operations while improving compliance and outcomes. According to the HealthEdge survey:

• 85% of health plan executives say regulatory pressures are significantly impacting margins
• 34% are turning to technology like AI and analytics to reduce costs
• An increasing number of health plan leaders are exploring outsourcing and shared services models, recognizing their promise in balancing cost, compliance, and modernization.

The Power of “AND”: Technology and BPaaS Together

Too often, health plans view BPaaS and technology modernization as separate strategies. But in today’s environment, success lies not in choosing between the two—but in using them together.

With the recent merger of HealthEdge and UST HealthProof, health plans now have access to a unified platform that combines best-in-class, AI-powered core technology with proven BPaaS capabilities. This new offering delivers what today’s health plans truly need: a scalable, intelligent, and compliant operational model that can reduce costs, boost agility, and enhance outcomes, all under one roof.

As stated in the official merger announcement, this new entity creates “a disruptive AI-powered healthcare health plan technology and services leader” designed to meet the end-to-end needs of modern health plans. Now, health plans no longer have to compromise between innovative software and high-performing services. They can have both: the platform and the people to drive results.

How the Combined BPaaS Model Works

According to a recent Everest Group report, Next-Generation BPaaS: A New Era of Efficiency for Health Plans, next-generation BPaaS can reduce total cost of ownership (TCO) by up to 50%, drive 95% enrollment automation, and increase claims auto-adjudication to 95% or more, especially when integrated with AI-powered technology platforms.

Here’s how combining BPaaS + technology delivers value across health plan priorities:

• Cost Efficiency: BPaaS embeds automation and analytics into core workflows, reducing manual labor and administrative spend. Pairing this with modern claims and care management platforms further cuts inefficiencies and TCO.
• Regulatory Agility: New mandates like OBBBA and interoperability rules from the Centers for Medicare and Medicaid Services (CMS) require real-time data exchange and governance. With a unified solution, health plans gain built-in compliance frameworks and the agility to adapt to changing requirements.
• Member and Provider Experience: Health plans can scale digital engagement, offer omnichannel support, and integrate provider data—improving satisfaction and reducing friction across the ecosystem.
• Speed and Scalability: With pre-configured, low-code tools and embedded AI, health plans can accelerate implementation, reduce time-to-value, and respond quickly to business changes.

Turning Insights into Action

The 2026 Health Plan Survey makes it clear: health plans are ready for change, but too many are still making isolated, tactical investments. To thrive in today’s climate, they need a cohesive operating model that merges advanced technology with operational execution.

HealthEdge provides this model, now offering an integrated solution that transforms the way health plans operate, enabling them to reduce costs, meet regulatory demands, and deliver the experience stakeholders and members have come to expect.

Download the full 2026 Healthcare Payer Survey Report, The Great Rebalancing: Inside the New Realities Shaping Health Plan Performance, to explore all the insights driving the more than 550 health plan leaders today.