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Data Sheet: Optimize Efficiencies with Integrated HealthRules Payer Solutions

HealthRules® Payer is a next-generation core administrative processing system (CAPS) designed to revolutionize the operations of health plans of all sizes and types.

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HealthEdge’s comprehensive HealthRules Payer platform empowers health plans to streamline operations and improve efficiency by providing an integrated solution that supports all core administrative and clinical processes. By leveraging innovative add-on solutions, health plans can extend the capabilities of the platform to address specific business needs, ensuring a more robust and optimized ecosystem for health plan management.

The following integrated HealthRules Payer solutions are designed to drive operational excellence, regulatory compliance, and cost savings:

  1. HealthEdge RADAR: This solution provides real-time visibility into claims processing. By leveraging HealthRules Payer data, RADAR allows health plans to identify bottlenecks, measure operational performance, and make data-driven decisions to optimize efficiency and reduce costs. Key features include comprehensive dashboards and proactive issue identification.
  2. Single Sign-On (SSO): SSO simplifies user authentication and access management for HealthRules Payer and its integrated solutions. By providing a secure, centralized login, it enhances user experience, improves security, and reduces administrative overhead, allowing users to access multiple applications with a single set of credentials.
  3. HealthRules Promote: This tool automates the complex process of moving configurations between environments (development, testing, production). It ensures accuracy and compliance while reducing manual errors. HealthRules Promote facilitates easy auditing and tracking of changes, significantly decreasing the time required for configuration tasks.
  4. SmartComm: Empowering health plans to deliver personalized member and provider communications, SmartComm integrates seamlessly with HealthRules Payer. It enables automated, compliant messaging across multiple channels to improve engagement and reduce operational costs.
  5. Machine Readable Files (MRF) Suite: The MRF Suite provides end-to-end support to generate, manage, and publish machine-readable files as mandated by the Transparency in Coverage (TiC) Final Rule. It streamlines the ingestion of negotiated service rates and allowed amounts from external sources, ensuring regulatory compliance.
  6. HealthRules EDI Gateway: This centralized hub efficiently manages the exchange of electronic data interchange (EDI) files. It automates communication, validation, and integration between diverse systems, supporting a broad range of transaction types (e.g., 837, 835) to enhance data accuracy and foster better collaboration with providers.
  7. HealthEdge Provider Data Management (PDM): PDM is a comprehensive solution designed to streamline the management of provider data. It ensures the accuracy and completeness of information critical for claims processing and network management. Features include a low-code framework using generative AI and a centralized data quality engine to prevent data loss.

By implementing these integrated HealthRules Payer solutions, health plans can achieve significant operational improvements, from enhanced data-driven decision-making and reduced administrative burdens to strengthened regulatory compliance and superior member experiences.