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Medicaid programs nationwide are increasingly requiring and incentivizing health plans to incorporate whole-person care and the social determinants of health (SDOH) into their service models. Recognizing SDOH’s significant influence on health outcomes and costs, Medicaid programs are encouraging payers to move beyond traditional clinical care and focus on holistic approaches that address the underlying social needs of vulnerable and high-risk populations.

Initiatives such as California’s CalAIM exemplify this shift, implementing high-touch member services and support for housing, food, and other physical, behavioral, and social needs. These efforts are especially important for high-risk populations.

Similarly, other state programs, including North Carolina’s Healthy Opportunities Pilot, Michigan’s Health Equity Project, and Arizona’s Whole Person Care Initiative, challenge payers to adopt integrated care strategies that meet members’ social needs alongside their medical needs. These programs set new care management standards, often requiring partnerships with community organizations to deliver services that can positively impact long-term health outcomes.

Integrating SDOH into Digital Care Management

Adapting to these new standards calls for a comprehensive approach to addressing SDOH. This is where technology platforms integrated with social care networks, such as Unite Us, become essential. The integrated GuidingCare and Unite Us solution provides health plans with the ability to seamlessly coordinate social services, creating a more efficient, impactful whole-person care model that aligns with evolving Medicaid requirements across the U.S.

By incorporating SDOH data into the GuidingCare platform, care managers can gain a 360-degree view of their members’ health, allowing for more personalized and effective care plans. This holistic approach addresses not just clinical care needs through GuidingCare but also provides referrals to services that improve social and environmental factors, which significantly impact health outcomes

What Is Unite Us?

Unite Us is a technology company that builds coordinated care networks of health and social service providers. Their platform offers health plans access to one of the nation’s largest networks of social service providers, enabling efficient referrals for housing, food, transportation, and employment services across the United States.

The GuidingCare and Unite Us SDOH Integration

The integration between GuidingCare and Unite Us enables seamless data exchange and document sharing directly within the GuidingCare interface.

Key benefits of this integration include:

• Improved Interventions. GuidingCare users can effectively identify social care needs, refer members to appropriate services, confirm service delivery, and track outcomes.
• Access to Coordinated Care Networks. The Unite Us coordinated care network allows care managers to connect members to a wide range of social services and resources within GuidingCare.
• Holistic View of Member Health. Care managers have access to a comprehensive view of members’ health, covering both clinical and non-clinical factors that impact outcomes.
• Improved Quality Measures. By addressing social factors, health plans can positively impact member outcomes while strengthening their organization’s quality measures
• Streamlined Workflow. SDOH interventions can be efficiently incorporated into care plans and managed directly within the GuidingCare platform.

GuidingCare and SDOH

The integration with Unite Us is just one part of HealthEdge’s broader approach to embedding SDOH data into care management workflows. By systematically incorporating SDOH into the GuidingCare platform, health plans can better adapt to evolving Medicaid programs. Care managers, in turn, can efficiently coordinate whole-person care and connect members to vital services.

HealthEdge is committed to innovation, collaboration, and delivering solutions that address all aspects of members’ health. To learn more about how GuidingCare’s SDOH integrations can transform healthcare for your organization, visit our website or contact us today. Together, we can work towards a healthcare system that addresses all aspects of members’ health.

To stay ahead of complex payment models and billing guidelines, healthcare payers are turning to integrated digital solutions that can help streamline operations to achieve key business goals. Approaching payment integrity using disparate systems often results in unnecessary reworks and higher administrative costs. With an enterprise payment accountability approach, health plans can avoid improper payments and reduce recovery fees.

Payment Accountability®: A Proactive Approach to Payment Integrity

Payment Accountability® from HealthEdge Source™ shifts the focus from post-payment recovery to proactive cost avoidance practices. By integrating claims processing workflows and optimizing pre-pay processes, health plans can reduce processing times and strengthen financial performance.

A Comprehensive Solution for Greater Control

HealthEdge Source Platform Access empowers health plans to enhance payment integrity at every level. Advanced analytics, custom editing tools, and real-time insights give payers more control over their payment processes, and achieve key benefits such as:

• Root-cause detection: By analyzing historical claims data, health plans can uncover policy gaps, identify outliers, and detect configuration issues before they lead to costly errors.
• Quick & easy adjustments: Advanced Custom Editing lets health plans quickly create and customize edits and analyze past claims for increased accuracy. This simplified eliminates delays and reduces dependence on external vendors for execution and maintenance.
• Enhanced transparency and control: With a centralized platform, health plans gain real-time visibility into their payment integrity processes—helping ensure payment accuracy and regulatory compliance.

Our integrated technology, combined with our consultative partnership, helps health plans proactively manage claims processing and payments. HealthEdge  Source platform gives health plans greater control over their intellectual property, addresses root cause issues, and eliminates recurring administrative waste to support enterprise payment accountability.

Payer-Source Integration

The Payer-Source integration between HealthEdge Source and  HealthRules® Payer will be another pivotal step towards achieving an enterprise approach to payment integrity. By connecting all claims processing functions through a single platform, HealthEdge Source empowers health plans to manage their payment integrity programs more effectively. This effort enhances transparency between core platform and payment integrity functions.

By aligning disparate functions into a unified system, health plans can benefit from:

• Improved Payment Accuracy: Libraries of pricing and editing data, updated biweekly, lay the groundwork for industry-leading accuracy.
• Holistic Claims Adjudication: Editing can be applied effectively at multiple stages of the workflow, minimizing errors and reducing redundancies.

This centralized approach creates a bottom-line impact for enterprises, improving productivity while reducing overhead costs associated with fragmented systems.

Real-World Impact: Transforming a National Health Plan 

A major national health plan partnered with HealthEdge Source to address key challenges with achieving payment accuracy and workflow efficiency. The health plan leveraged the HealthEdge solution suite to streamline claims processing and payment management across the organization.

After adopting the integrated HealthEdge Source solution, the health plan accomplished notable improvements across performance and financial goals. Key achievements include:

• 30-40% reduction in resource-intensive contract maintenance
• Managed 70% self-funded business on a single platform
• Eliminated processing delays and improved claims transparency

• “The flexibility, configurability, and transparency of HealthEdge Source have been pivotal in our journey, resulting in measurable savings and operational improvements,” said the payer’s VP of Operations shared. “This partnership has truly transformed our approach to payment accuracy and operational efficiency.”

With the abilities to continually adapt to both competitive market demands and evolving regulatory requirements, the organization’s enterprise-wide payment integrity transformation positions it for long-term success and industry leadership.

Opportunities in Payment Accountability

Disruption isn’t just about changing for the sake of change. It’s about understanding that yesterday’s systems weren’t built to handle tomorrow’s demands. Health plans should recognize the need to challenge outdated norms in favor of strategies that position them for long-term success.

By embracing a coordinated, technology-driven approach to payment integrity, health plans can move beyond cost savings to set new standards in transparency, accountability, and operational excellence—ensuring they are ready for the challenges of tomorrow.

See how a provider-owned health plan leveraged the HealthEdge Source Payment Integrity solution to streamline operations, improve accuracy, and enhance provider transparency. Read the case study: SummaCare’s Secret to Payment Integrity Success

 

The healthcare industry is evolving at a rapid pace. Regulatory demands, shifting consumer expectations, and the need for data-driven decision-making are placing unprecedented pressure on health plans. The challenge is clear—how can payers remain competitive while meeting the growing complexities of modern healthcare?

This is where a next-generation Core Administrative Processing System (CAPS) like HealthRules Payer comes in. Designed to empower health plans with real-time data and unparalleled flexibility, this innovative system enables organizations to expand offerings and serve new member markets with ease.

How Health Plans Can Expand to New Markets with Modern CAPS

Health plans operate in an increasingly demanding environment. The traditional, hard-coded administrative systems of the past are ill-equipped to keep up with today’s healthcare landscape. A next-generation CAPS solution does more than process claims and manage benefits—it becomes the foundation for achieving strategic growth, operational efficiency, and superior member experiences.

With a next-generation solution like HealthRules® Payer, health plans can:

• Understand diverse member populations with real-time data and analytics.
• Quickly configure and launch new benefits offerings.
• Expand into new markets to capture valuable growth opportunities.

By leveraging a modern CAPS, health plans can move faster, adapt smarter, and make better-informed decisions—all while lowering administrative costs.

Real-World Transformations with HealthRules Payer

Health plans of all sizes have chosen HealthRules Payer as a technology partner for its ability to scale, adapt, and transform payer operations. See an overview of how three different health plans leveraged the HealthRules Payer CAPS solution to configure new offerings and expand to new markets.

Medica Health Plan

Medica, a regional health plan managing over 1 million lives, partnered with HealthEdge to streamline existing lines of business and expand its benefit offerings by reducing time to market.

Key Achievements:

• Configured 81 benefit plans in just 10 days using only four resources.
• Responded to new market opportunities in real time, leveraging accurate and actionable data.
• Automated manual processes across existing business lines, significantly reducing administrative costs.

“Data is the most valuable asset that health plans have.”

-VP of Business Transformation at Medica.

McLaren Health Plan

McLaren faced mounting inefficiencies with its outdated legacy system, including a low auto-adjudication rate. With the integrated CAPS solution from HealthRules Payer enabled McLaren to modernize their operations and respond to industry changes faster—which better positions the organization for long-term growth.

Key Achievements:

• Achieved a 90% auto-adjudication rate, reducing reliance on manual claims processing.
• Increased operational efficiency, allowing staff to reallocate resources toward innovation.
• Seamlessly expanded membership to 620,000 lives, bolstering business performance.

“HealthRules Payer has made reporting better and quicker, enabling us to operate with greater efficiency as we scale.”

-VP of Business Information & Operations at McLaren Health Plan.

Presbyterian Health Plan

Processing over 9 million claims annually, Presbyterian Health Plan required a flexible CAPS to manage growing complexities and maintain compliance. They leveraged the HealthRules Payer solution to automate claims processing, improve responsiveness, and adapt to shifting industry demands.

Key Achievements:

• Reduced claims turnaround time to under 5 days, ensuring prompt provider payments.
• Increased staff productivity by 30%, measured by the number of claims processed per hour.
• Enhanced benefits configuration efficiency by 40%, enabling rapid product launches.

“The configuration capabilities within HealthRules Payer are phenomenal. We’ve been able to make changes in half the time it took us previously.”

-VP of Claims Operations at Presbyterian Health Plan

What Sets HealthRules Payer Apart from other CAPS solutions

HealthRules Payer offers distinct advantages that make it a go-to choice for health plans seeking to modernize their administrative systems. Here’s what differentiates it:

1. Flexibility, Scalability, and Resilience

The HealthRules Payer CAPS is designed for flexibility and scalability, allowing payers to adapt to regulatory shifts, market trends, and emerging member needs for long-term viability.

• Real-Time Data Insights: Access accurate data instantly to make informed decisions and respond to opportunities ahead of competitors.
• Regulatory Compliance: Easily modify rules, produce auditable information, and adapt to regulatory requirements without disrupting operations.
• Faster Time-to-Market: Configure, review, and deploy new benefit offerings with unmatched speed and precision.

For McLaren Health Plan, this adaptability enabled rapid adaptation to industry changes, providing a significant edge in a competitive market.

2. Adaptability to New Business Models

The healthcare landscape is shifting from fee-for-service to value-based care (VBC), requiring payers to adopt more complex reimbursement structures. HealthRules Payer excels in enabling value-based reimbursement by:

• Designing and implementing benefit plans in less time and at lower costs than traditional systems.
• Sharing critical insights from data analytics with providers, improving performance metrics and creating stronger partner relationships.

For example, HealthRules Payer’s natural language capabilities have improved first-call resolutions at Presbyterian Health Plan, building trust and reducing callbacks—a direct reflection of enhanced service and data transparency.

3. Automation and Efficiency

Move away from manual workarounds and legacy inefficiencies. HealthRules Payer automates major processes, driving seamless operations that save both time and money. From claims processing to reporting, automation fosters:

• Higher accuracy
• Reduced operational costs
• Scalable business expansion

For example, Medica’s adoption of HealthRules Payer eliminated costly manual processes, improving productivity across Individual & Family, Medicare, and Commercial Group business lines.

The Competitive Edge for Health Plans

By implementing HealthRules Payer, health plans gain more than just operational efficiency—they secure a competitive advantage. Some key benefits include:

• Faster Response Times: Adapt to regulatory changes and industry demands in record time.
• Cost Efficiency: Lower administrative costs with streamlined, automated operations.
• Market Growth: Launch differentiated offerings ahead of competitors, capturing new members and revenue streams.
• Superior Member Experience: Deliver accurate, personalized service with easy-to-access data and insights.

With health plans increasingly vying for consumer loyalty, having a robust CAPS solution provides the tools needed to stand out in a crowded marketplace.

Do you want to learn more about how the next-generation CAPS from HealthRules Payer can empower your health plan to expand to new markets? See how a regional health plan achieved a 90% auto-adjudication rate, opened new lines of business, and expanded to new states. Read the case study.

Health plan members no longer seek transactional healthcare interactions—they expect personalized, accessible, and engaging experiences. For health plans, meeting these expectations isn’t just desirable—it’s essential. To meet this increasing demand, payers are investing in integrated solutions that can help them streamline workflows, deliver personalized care, and empower members.

These solutions not only enhance member satisfaction and clinical outcomes but also give payers a competitive edge in an increasingly complex market.

This blog explores how leading health plans are investing in care management workflow software, AI tools, and self-service digital resources to deliver world-class member experiences and boost CMS Star Ratings.

The Shift Toward Personalized Care

Today’s healthcare consumers want to feel like more than just policy numbers. They want healthcare options that offer the convenience, clarity, and customization they’ve come to expect with their retail experiences. According to recent surveys, 59% of members expect health plans to prioritize health equity, while 52% cite a demand for self-service tools.

Personalized care has more benefits than just meeting members’ expectations. It can also help improve health literacy, increase preventive care utilization, and contribute to better care outcomes. The value of personalization for health plans goes far beyond member satisfaction—engaged members are healthier members, which translates to fewer hospitalizations, greater satisfaction, and higher retention rates.

To meet member expectations, health plan executives are turning to three core digital investments.

Top Areas of Digital Investment for Healthcare Payers 

Health plan leaders strategically dedicate resources to technologies that drive operational efficiency, reduce administrative burdens, and place members at the center of their strategies.

1. Care Management Workflow Software 

Care management workflow software provides the critical infrastructure to streamline and optimize care delivery. These tools improve coordination between care teams, reduce inefficiencies, and enable real-time data sharing for seamless decision-making.

GuidingCare® is an industry-leading solution that integrates care management, population health, and utilization management into a unified platform. With features like automated care planning and advanced care coordination tools, GuidingCare helps payers deliver whole-person care while freeing up staff to spend more time engaging directly with members.

Benefits of Care Management Workflow Software:

• Efficient Workflow Automation: Streamlines processes, reducing time-intensive manual tasks.
• Personalized Interventions: Supports tailored solutions by identifying high-risk members and alerting providers.
• Seamless Communication: Breaks down internal silos to help ensure care teams, providers, and members can communicate more effectively.

2. Artificial Intelligence  

AI is already making an impact in healthcare, with its potential to provide actionable insights, automate repetitive tasks, and predict outcomes with precision. For health plans, incorporating AI tools allows for resource allocation and streamlined decision-making.

In addition, AI-powered predictive analytics can identify high-risk members who need immediate attention, enabling plans to proactively engage these individuals and close gaps in care before conditions worsen.

How AI Benefits Health Plans:

• Early Identification of High-Risk Members: AI can forecast member health risks and recommend timely interventions.
• Improved Administrative Efficiency: Automates claims processing and fraud detection, saving valuable resources.
• Higher Member Satisfaction: AI tools can help personalize communications, making members feel valued.

3. Self-Service Digital Resources 

Instead of traditional phone calls, members increasingly demand the convenience of self-service tools that give them access to their health history, benefits information, and care programs. Empowering members to manage aspects of their health journey not only improves satisfaction but can also increase member touchpoints and extend existing resources.

The GuidingCare integration with Wellframe delivers digital checklists and personalized health reminders, helping members stay engaged with their care plans. Wellframe offers more than 70 digital care programs, an on-demand resource library, and personalized daily health checklist that supports members wherever they are on their health journeys.

Benefits of Self-Service Tools:

• Empower Members: Enable members to check coverage details, schedule preventive screenings, and access educational content.
• Reduce Friction: Lower costs and make healthcare services more accessible and transparent.
• Enhance Member Engagement: Provide reminders and tools aligned with the member’s unique health goals. Members who use the Wellframe solution average 34 interactions per member per month.

Real-Life Impact: Nonprofit Health Plan

One nonprofit health plan partnered with HealthEdge® to modernize its digital care solutions. By integrating GuidingCare with HealthRules® Payer, the payer was able to reduce administrative fragmentation and offer its million-plus members a better, more efficient healthcare experience. This transformation improved data accuracy and strengthened member trust—essential elements in a competitive healthcare marketplace.

The healthcare industry is being reshaped by rapid advancements in technology, and health plans must adapt to thrive. By investing in these innovative tools, health plans can create meaningful member experiences, improve health outcomes, and stay competitive in a field where personalization is the key differentiator.

Learn more about the trends driving health plan investment and modernization. Download the HealthEdge Annual Payer Market Planning Report 2025

Health plans face a variety of challenges when it comes to contract modeling, negotiations, and reviews. A reliance on manual processes and disparate tools can make it difficult to accurately evaluate the financial impacts of new provider contracts.

In a recent webinar, healthcare industry experts shared their experiences working with health plans to improve accuracy and scalability in the contract review process. This blog highlights key insights from the virtual session that can help transform hypothetical conversations into actionable, data-driven negotiations.

5 Challenges Health Plans Face During Contract Negotiations

During the webinar, we polled the audience to better understand their major challenges. 80% of respondents said, “inefficiencies due to manual processes” were their primary concerns, followed by “lack of accurate insights into contract terms.”

What is the biggest challenge your health plan faces during contract negotiations?

• Inefficiencies due to manual processes (80%)
• Lack of accurate insights into contract terms (20%)

1. Manual Processes: Many health plans still rely on outdated tools, such as spreadsheets and pivot tables, to model contract scenarios. These manual methods are error-prone, time-consuming, and inflexible, leading to delays in negotiations and decision-making.

2. Lack of Accurate Insights: Without timely and accurate information, health plans struggle to understand the financial implications of certain contract terms. This includes challenges in analyzing how payment term changes affect reimbursements or savings, hindering their ability to make informed decisions.

3. Disjointed Systems and Data Sources: The workflows for contract negotiations often involve disparate tools and systems. These siloed environments make it hard to analyze and reconcile data, leading to unnecessary complexity when assessing contractual impacts.

4. Configuration Challenges: After contracts are finalized, health plans sometimes discover that the terms cannot be efficiently configured into their existing claims processing systems, causing operational bottlenecks and delays in implementation.

5. Lag Time Between Contract Finalization and Execution: There is often a gap between signing a contract and getting it fully operational. This lag time can result in delays in reimbursement or improper payments, creating friction between stakeholders.

These challenges not only create inefficiencies that cost time and resources but also compromise the accuracy of contract modeling.

What-If Modeling: Our Vision for a Better Solution

At HealthEdge Source™, our team is developing a solution to eliminate these challenges by bringing advanced technology and seamless workflows into the contract negotiation process. The HealthEdge Source What-If Modeling tool will allow health plans to envision, evaluate, and execute contract scenarios with unprecedented precision.

During the webinar, we demonstrated the solution and asked what participants found most valuable about the tool for their organizations. The top answers were:

• Real-time modeling of contracting change (33%)
• Comprehensive variance reports (33%)
• User friendly interface and ease of use (33%)

Increasing Contract Value for Health Plans 

• Automation and Real-Time Modeling: HealthEdge Source What-If Modeling is designed to replace manual processes with automated workflows, allowing health plans to build, test, and analyze contract configurations in minutes. Health plans will also be able to model complex scenarios in real time, significantly reducing the time and effort required to optimize contracts.
• Precision in Financial Insights: With penny-precise modeling for various reimbursement terms, health plans will be able to better anticipate the financial impacts of their contracts with greater accuracy, increasing confidence in projections and negotiations.
• Unified Platform for Disparate Processes: The new tool will bring together all critical functions—such as claims editing, pricing, and advanced analytics into a single platform. This will eliminate the need for multiple disparate systems and create a cohesive environment for assessing data and contracts.
• Self-Service Accessibility: With a user-friendly interface, the solution will empower contract negotiation teams to independently configure, compare, and adjust contract terms. Teams will be able to run “what-if” scenarios to evaluate potential impacts without relying on external support.
• Seamless Integration with Existing Systems: It will integrate smoothly as a modular component of  HealthEdge Source. It can also function as a standalone system, allowing health plans to leverage the tool within their existing ecosystems.
• Reduced Lag Time: The tool will directly convert modeled contracts into production-ready configurations, significantly reducing the time needed to operationalize agreements. This will help ensure accurate reimbursements from the start, while preventing downstream inefficiencies and rework.

HealthEdge Source What-If Modeling will support various complex contract structures, including carve-outs for specific services (e.g., ER visits) or alternative payment models like capitation. These features were developed to make it easier for health plans to negotiate and model deals that align with their financial objectives and operational capacities.

Supporting a Collaborative Approach to Change 

With the tool, health plans can bridge the gap between contracting and configuration teams, encouraging collaboration that helps determine whether contract terms are feasible. By identifying potential configuration issues during the modeling phase, health plans can minimize surprises and shorten implementation time. This approach can also help reduce provider abrasion and better inform contracting teams of the potential impact of custom configurations.

The Road Ahead for What-If Modeling

We invite you to watch the webinar recording to see a demo of the HealthEdge Source What-If Modeling tool in action and learn more about its functionalities. Discover how this innovative solution can transform your contract modeling process and deliver unparalleled precision and efficiency. Watch the webinar on-demand

Together, we can transform the way health plans approach contract modeling and create impactful results. If you’d like to contribute feedback or participate in our beta testing phase, we’d love to hear from you! Current customers can reach out to their Customer Success Managers for more inform