Automate & Accelerate Health Plan Rules Deployment with HealthEdge GuidingCare® 

The healthcare industry is in constant motion. Regulations change and care models evolve, while competitive pressures and member expectations grow more complex every year. For health plans, this pace of change challenges how quickly they can adapt and serve members without introducing delays or costly workarounds.

At the heart of this challenge are the internal business rules that define how payers manage care, process authorizations, generate alerts, and manage exceptions. When rules and processes fall behind market demands, organizations face various risks: members may encounter gaps in care, and care teams could struggle to provide coordinated care. When business rules aren’t quickly updated to reflect regulatory changes, compliance risks increase, leading to audit issues and potential financial penalties. Additionally, when health plans depend solely on third-party vendors for automated rules management, they may face slower turnaround times and higher costs.

The HealthEdge GuidingCare® Rules Designer helps by enabling business agility for health plans. Powered by the GuidingCare Rules Engine, GuidingCare Rules Designer gives health plans control over how rules are created, tested, and deployed. Instead of waiting for third-party vendors or navigating complex release cycles, technical users can make direct changes. The result is faster adaptation and better support for members and care teams.

Where Advanced Rule Execution Meets Easy, Visual Design

At its core, the GuidingCare Rules Designer is a purpose-built user platform for writing, testing, and deploying rules. While the GuidingCare Rules Engine provides the back-end execution, the Rules Designer makes it accessible through a modern, intuitive environment.

Traditional rule management often forces users into proprietary languages or cumbersome development frameworks. With GuidingCare Rules Designer, the process is visual and interactive. Analysts and developers can build flows, test scenarios, and refine logic with speed and agility. For the first time, health plans have a tool that supports technical users in a collaborative and flexible design space.

Key features of the GuidingCare Rules Designer include:

• Visual Rule Modeling: Users can design rules through a graphical, point-and-click interface to visually model relationships and dependencies. This feature provides a clear understanding of the rule’s function and intent when building out complex logic.
• Built-in Testing Suite: Simulate real-world scenarios and step-through decision paths with advanced debugging tools to ensure rules work as intended before deployment.
• Flexible Rules Deployment Options: Deploy to quality assurance (QA) or pre-production environments on demand, independent of release cycles, allowing teams to implement updates or compliance changes without delay.
• Concurrent Development: Enable multiple users to work within the same rule set simultaneously, improving collaboration and eliminating time consuming handoffs in rule creation.

From Faster Rules Deployment to Better Care and Compliance

GuidingCare customers leverage the Rules Designer to achieve meaningful strategic advantages and meet industry demands, such as:

Enhanced speed and performance: Users can design, test, and deploy new rules in days rather than weeks, achieving faster runtime, execution, and responsiveness for even the most complex workflows.

Organizational autonomy: Payers can reduce reliance on third-party vendors, keep sensitive data in-house, and give technical teams ownership of business logic.

Regulatory agility: Users can update rules quickly to align with evolving requirements from the Centers for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA), strengthening audit readiness and compliance confidence.

Operational efficiency: The solution allows users to automate workflows to reduce manual effort and standardize processes, freeing care teams from the cumbersome administrative tasks that stand in the way of delivering focused, quality care to members.

Care coordination: With integrated alerts, care teams can detect missed preventive or clinical interventions and trigger targeted outreach for members who need it most.

Implementing Health Plan Rules Transformation

For a technical analyst at a health plan, the new workflow with GuidingCare Rules Designer is both intuitive and fast. Instead of submitting requests to an outside vendor and waiting for the next release cycle, the analyst can log into the Rules Designer and build rules directly in the visual flow editor.

Analysts can create logic to generate alerts for missed preventive screenings, set up automated authorizations, or trigger care management workflows based on clinical data. A powerful set of debugging and troubleshooting tools ensure high confidence and quality.

With the GuidingCare Rules Designer, new rules can be live in production within days. This can include custom care team notifications and updated workflows, empowering them to act with confidence—from member outreach and documentation to care coordination. Processes that once required weeks of back-and-forth can now be completed with speed, accuracy, and control.

Built for Today, Ready for Tomorrow

The first release of GuidingCare Rules Designer is already transforming how health plans manage workflows. And just as importantly, it helps lay the foundation for continued innovation.

HealthEdge® is investing in ways to make the tool even more powerful, including expanding visibility into how rules operate, offering more flexible deployment options, and improving user-friendliness for non-technical users. Future enhancements will also enrich rule logic with broader data sources and emerging technologies.

This forward-looking approach reflects the HealthEdge vision of a care management platform that not only keeps pace with change but helps drive it.

Start Adapting Your Business with Confidence

GuidingCare is trusted by health plans covering more than 30 million members. With the GuidingCare Rules Designer, our health plan partners can gain greater control over how care is coordinated, customized, and delivered. The solution is purpose-built to address the complexity of modern healthcare, enabling plans to adapt more quickly and operate more efficiently.

The future of care management depends on flexibility, control and speed. The GuidingCare Rules Designer delivers all three, empowering technical teams to build and deploy workflows with confidence.

Discover how VillageCareMAX enhanced reporting and operations by partnering with GuidingCare. Read the Case Study.