Data Sheet: Emerging Solutions Spotlight

HealthEdge Source™ is a cloud-based, prospective payment integrity solution engineered to unify claims pricing, editing, and analytics. It empowers health plans to ensure accurate and compliant claims payments before they are made, transforming claims processing with unparalleled accuracy, efficiency, and cost savings. By automating complex reimbursement processes and delivering real-time insights, Source helps reduce payment errors, lower administrative costs, and strengthen provider relationships.

For a complete overview of the platform's capabilities, view the HealthEdge Source™ Product Overview.

The HealthEdge Source Advantage: Differentiating Technology

The platform's architecture is designed to provide health plans with control, transparency, and future-ready functionality. Its foundation is built on a unified and efficient model that eliminates the need for fragmented, black-box solutions.

• Single Instance: Connects to all your claims systems and handles all lines of business from one centralized platform.
• Single Transaction: Manages editing, pricing, auditing, and business intelligence in a single, cohesive process.
• Single Configuration Layer: Consolidates your intellectual property, Source content, and third-party rules in one manageable layer.
• Cohesive Workflow: Streamlines interactions between all claims processing functions for maximum efficiency.
• Cloud-Hosted Infrastructure: Delivers automated content delivery and eliminates the need for on-premise hardware management.
• Rapid Update Cycle: A two-week update cycle ensures you always have the most current content and rules.
• Centralized Data: Enables integrated, real-time audit and analytics functionality for immediate business insights.

Core Dimensions of Value for Health Plans

HealthEdge Source delivers value across critical operational areas for health plans, from reimbursement to platform-wide control.

Medicare & Commercial Reimbursement

Optimize your reimbursement processes for both Medicare and commercial lines of business.

• Achieve accurate modeling of complex reimbursement scenarios.
• Simplify provider contract configuration and management.
• Increase payment accuracy with user-friendly tools.
• Enhance automation to reduce manual intervention.

Advanced Claim Editing

Gain control over your claim editing rules to reduce dependency on external vendors and address issues at their origin.

• Build, model, and implement custom edits with precision.
• Reduce reliance on third-party vendors for editing content.
• Address root-cause payment issues proactively.
• Decrease the burden on IT and operational teams.

Total Solution Platform Access

Leverage the full power of an integrated platform for a proactive, enterprise-wide approach to payment integrity.

• Unlock root-cause remediation for systemic issues.
• Implement a proactive and preventative payment strategy.
• Drive enterprise-wide alignment on payment policies.
• Increase ownership and control over your payment integrity operations.

A Modernized Workflow for High-Speed Payment Accuracy

HealthEdge Source facilitates a "virtuous cycle" of ideation, testing, implementation, and analysis. This end-to-end process dramatically increases deployment speed, allowing health plans to move from concept to production savings with unprecedented agility. Learn more about how to take a proactive approach with HealthEdge Source.

1. Test and Validate with What-If Modeling (SWIM): Forecast the financial impact of new edits using historical claims data before deployment. This provides the concrete data needed to gain internal approval and refine logic.
2. Collect Real-Time Data with Monitor Mode: Run new edits passively on live production claims without affecting adjudication. This builds confidence by tracking the potential impact of policies in a live environment without financial risk.
3. Educate Providers with Informational Edits: Set an edit's disposition to "informational" for a defined period. This returns a message on the Explanation of Benefits (EOB) to proactively educate providers on new policies before they impact reimbursement.
4. Automate Retrospective Analysis with RCM: The Retroactive Change Management (RCM) tool automates the identification of claims paid incorrectly prior to a policy change, streamlining recovery and facilitating transparent communication with providers.

Building Custom Payment Policies with Advanced Custom Edits

The Advanced Custom Edit tool allows payment integrity teams to design and implement highly specific policies via an intuitive, point-and-click interface.

Validated by Industry Recognition: Best in KLAS

HealthEdge Source™ was named “Best in KLAS” for Pre-Payment Accuracy & Integrity Solutions (Payer) in the 2026 KLAS report. This recognition is a direct result of in-depth interviews with healthcare payers, who rated Source highly for its product functionality, customer satisfaction, and long-term value. With an overall score of 88.2, the platform significantly surpasses the market segment average.

Explore the full results in the HealthEdge Source™ Wins “Best in KLAS®” data sheet.

Key Performance Metrics

Furthermore, 100% of customers confirmed they would purchase the solution again and include it in their long-term strategic plans.

HealthEdge Source by the Numbers

The platform's performance and scale are demonstrated by key operational metrics.

Explore Payment Integrity Resources

By adopting a modernized, user-driven approach, health plans can break down the barriers that prevent efficient cost management. HealthEdge Source empowers plans to shorten implementation cycles, ensure billing accuracy, and maximize savings.

To explore additional articles, case studies, and webinars, visit our Payment Integrity Resource Hub.