Skip to main content
logo Contact us

Data Sheet: HealthRules Payer Home & Host Processing

Many health plans with home and host capabilities are compelled to seek out modern technologies to keep pace with their complex business needs and support their market-leading positions.

Download PDF

HealthRules Payer, a next-generation core administration system, empowers health plans with home and host capabilities to quickly launch new products and entire lines of business with increased speed to market. By integrating modern capabilities in real time, HealthRules Payer ensures seamless support for all core administrative operations, enabling members to access the same benefits across home and host plans without disruption.

Health plans can leverage HealthRules Payer’s advanced functions and enhancements to reduce complexity, eliminate data duplication, and lower total cost of ownership (TCO). Recognized by Gartner as a Sample Vendor for next-generation core administration systems for 12 consecutive years, HealthEdge provides a reliable solution designed to meet the complex needs of market-leading health plans while ensuring smooth implementation and shortened time to go-live. 

Seamless Integration and Technical Precision

HealthRules Payer creates a unified ecosystem for home and host health plans by leveraging advanced integration standards. The platform supports all aspects of the home and host program through production-ready capabilities:

  • Streamlined Service: The Home solution utilizes APIC3 for efficient Pricing and Disposition Format build.
  • Configurable Data Elements: The Host solution allows for the configuration of Submission Format data elements, enabling faster implementation of changes.
  • Shared Platform Access: HealthRules accesses software components and databases of Inter-Plan Teleprocessing Services (ITS) via a shared platform, utilizing batch file transfers or message-oriented middleware.

The HealthRules Advantage

By combining superior home and host capabilities with the robust functionality of HealthRules Payer, organizations can transform their business models to be more agile. Key strategic advantages include:

  1. Resiliency to Change: Plans can react swiftly to competitive pressures, regulatory shifts, and opportunities for expansion. The system is certified for bi-annual home and host releases to ensure ongoing compliance.
  2. Operational Efficiency: Customers achieve auto-adjudication rates over 90% with at least 99% accuracy. Automation eliminates waste and maximizes resource allocation.
  3. Flexibility of Configuration: Powered by the HealthRules Language—a patented, English-like vernacular—business analysts can configure benefit plans and provider contracts in hours rather than months, without reliance on IT resources.
  4. New Business Models: The platform's agility equips plans to launch new lines of business, such as Accountable Care Organizations or Medicaid expansion, in a matter of weeks.
  5. Ease of Integration: HealthRules Payer integrates with top systems in real-time using advanced APIs, creating a cost-effective, low-risk IT ecosystem. It enables seamless collaboration with third-party vendors, partner solutions, or internal systems, cutting implementation and maintenance costs.
  6. Actionable Insights: All data is available via feed to a data warehouse, providing real-time transparency that improves patient outcomes and lowers costs.

Conclusion

Legacy claims processing solutions are ill-equipped to handle the demands of the new healthcare economy. HealthRules Payer for home and host health plans offers lasting innovation, addressing regulatory compliance and payment reform while enabling plans to lower costs and maximize efficiency. By adopting this next-generation solution, health plans can position themselves to innovate, compete, and succeed in an evolving marketplace.