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Next-Generation Core Administrative Processing Solutions: A Top Priority for Many Payers

The healthcare landscape is in a constant state of evolution, with technology innovations serving as a guiding force for payers striving for efficiency, accuracy, and enhanced operations. In this journey, the Gartner Hype Cycle for U.S. Healthcare Payers 20231 report delivers insight into the maturity levels and adoption rates of 28 different innovations. In this report, one of the innovation mentioned is next-generation core administrative processing solutions (CAPS).

For the 13th consecutive year, HealthEdge, has been recognized as a Sample Vendor in the report, under the category next-generation core administrative processing solutions (CAPS).

We believe this recognition underscores HealthEdge’s commitment to innovation, excellence, and its unwavering pursuit of transformative solutions.

The Power of HealthRules Payer

HealthRules Payer is more than just a solution; it’s a catalyst for transformation in the healthcare payer domain. Its unparalleled flexibility empowers health plans to embrace new business models, adapt to changing regulations, and expand into new markets seamlessly.

Elevating Business Impact

Next-generation CAPS like HealthRules Payer can have substantial influence across multiple facets of the healthcare insurance industry, including:

  • Efficiency Enhancement: HealthRules Payer reduces transaction costs, improves access to real-time data, and streamlines operations, ushering in a new era of operational efficiency.
  • Modern Architecture: HealthRules Payer supports real-time data and transaction processing through its modern architecture, bolstering the agility and responsiveness of health plans.
  • Adapting to Change: With HealthRules Payer, health plans can now embrace new business models, such as value-based payment arrangements, and capitalize on cloud technology’s economies of scale and security.
  • Simplified Integration: HealthRules Payer supports multiple interfaces that are configurable and user-friendly to ease the integration process with both payer and third-party applications.
  • Reducing IT Dependence: HealthRules Payer’s cloud-based infrastructure and advanced automation minimizes the reliance on IT resources, resulting in increased autonomy and operational efficiency.


In the report, Gartner analysts provide user recommendations to payers about considerations they should make when selecting a next-generation CAPS. These recommendations include:

  • Prioritize strategic versus commodity CAPS capabilities to evaluate investment decisions. The former include FHIR enablement, real-time processing or effective-now configuration to accommodate scenarios such as the Dobbs decision’s regulatory fragmentation.
  • Analyze whether licensed applications, SaaS or business process outsourcing (BPO and BPaaS) solutions for each CAPS capability are best.
  • Evaluate new versions of CAPS as greenfield. Old CAPS versions are not representative. However, weigh prior experience with vendor delivery heavily.
  • Search for modular CAPS components that allow a partial or phased implementation and prioritize solutions that offer configurable interfaces.
  • Validate the vendor’s primary market. Some CAPS have their most significant footprint in a segment like provider-led health plans, third-party administrators or dental. Consider whether influencing a vendor’s product roadmap outweighs the early adopter risk.
  • Address the diminishing resource pool available to support legacy systems. Updated technologies will entice job candidates.

A Brighter Future

To us, HealthEdge’s recognition in the Gartner Hype Cycle for U.S. Healthcare Payers, 2023 under the category next-generation CAPS reflects its dedication to shaping the future of healthcare payer operations. As the industry marches towards next-generation CAPS adoption, HealthRules Payer will undoubtedly continue to serve as a benchmark for excellence, innovation, and transformative solutions in the health insurance industry.

To learn more about how HealthRules Payer can help your organization adopt a next-generation CAPS, visit

1 Source: Gartner, Hype Cycle for U.S. Healthcare Payers, 2023. Mandi Bishop, Connie Salgy, Austynn Eubank, 10 July 2023. GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally, HYPE CYCLE is a registered trademark of Gartner, Inc. and/or its affiliates and are used herein with permission. All rights reserved.. Gartner does not endorse any vendor, product, or service depicted in its research publications and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner’s research publications consist of the opinions of Gartner’s research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.