Data Sheet:The HealthRules Payer Advantage: What Sets Us Apart

HealthRules Payer represents a modern core administration solution designed to help health plans overcome complex operational challenges. By leveraging advanced automation, real-time data, and a flexible architecture, HealthRules Payer empowers payers to achieve operational efficiency, adapt to new business models, and maintain regulatory compliance.

The HealthRules Advantage

HealthRules Payer is built on a single platform that integrates membership, benefits, claims, authorizations, and finance. This unified approach delivers exceptional performance across seven critical areas:

1. New Business Models: Accelerate product launches and adapt to alternative reimbursement methodologies.

• Expand into Medicare, Medicaid, and ancillary markets rapidly.
• Adopt value-based care programs like bundled payments and shared savings.
• Design and configure new products quickly to meet evolving market demands.

2. Operational Efficiency: Automate core processes to reduce errors and administrative overhead.

• Achieve auto-adjudication rates exceeding 90% and claims accuracy over 99%.
• Reduce manual effort with real-time automated claims reprocessing.
• Streamline workflows for improved data transparency and access.

3. Resiliency to Change: Respond swiftly to regulatory shifts and market dynamics using the patented English-like HealthRules Language™.

• Implement IT-independent configuration changes for immediate regulatory compliance.
• Adjust benefit levels and authorization requirements instantly during public health events.
• Launch new lines of business rapidly to capitalize on market opportunities.

4. Configure the Business: Reduce reliance on IT resources by empowering business analysts to manage routine configurations.

• Utilize reusable configuration templates for consistent and efficient process management.
• Deploy standardized product designs across environments with seamless import/export functionality.
• Automate the propagation of changes to minimize manual errors.

5. Ease of Integration: Lower maintenance costs and risk with a robust integration layer via HealthRules Connector.

• Facilitate real-time and batch data exchanges across the healthcare ecosystem.
• Reduce implementation timelines with pre-built integrations and standard interfaces.
• Ensure system compatibility through continuous automated testing.

6. Insights for the Business: Drive strategic decision-making with real-time analytics and predictive tools.

• Access immediate insights via analytics dashboards for finance, operations, and care teams.
• Simulate new product designs and reimbursement models to reduce financial risk.
• Leverage predictive tools like Benefit Predictor to anticipate claim outcomes proactively.

7. Reimagined Upgrades: Access the latest innovations with minimal disruption through the SaaS Included Upgrade program.

• Execute frequent, managed upgrades without additional professional services fees.
• Maintain compatibility of custom code automatically to avoid remediation costs.
• Decrease upgrade timelines to adopt new features swiftly.

HealthRules Payer offers a distinct competitive advantage by combining unmatched flexibility with real-time intelligence. This modern core administration solution allows health plans to streamline operations, enhance member care, and navigate the future of healthcare with confidence.

Learn more about how HealthRules Payer can modernize your health plan at HealthEdge.com.