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Data Sheet: HealthEdge HealthRules® Payer AI

Published Date

HealthRules® Payer is leveraging AI to define the next-generation core administrative processing system with unprecedented automation, agility, and insight.

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Artificial Intelligence (AI) is rapidly reshaping the future of health plans, offering the potential to revolutionize operations and care delivery.

As health plans embrace the power of AI to improve efficiency and enhance decision-making, HealthEdge introduces HealthRules® Payer AI. This suite of advanced capabilities is designed to transform health plan operations through a strategic focus on intelligent claims operations, proactive care, and elevated member experiences.

Transforming Operations with Health Payer AI

HealthEdge’s approach to Health Payer AI moves beyond simple automation to deliver agentic and generative AI solutions that drive meaningful outcomes. By integrating these advanced technologies, HealthEdge empowers health plans to adapt to dynamic market changes while maintaining operational agility.

The solution focuses on three core areas of transformation:

  1. Intelligent Claims Operations: Automate every aspect of claims adjudication with AI, including contract management, adjudication, fraud detection, and improved financial accuracy.
  2. Proactive & Integrated Care: Improve care and cost outcomes while driving care team quality and efficiency through predictive insights, automation and tailored care support.
  3. Elevated Member & Provider Experience: Enable personalized experiences at scale to meet member and provider needs across intelligent content, workflows and data.

A Commitment to Responsible AI Governance

Recognizing that healthcare is a risk-averse industry, HealthEdge prioritizes safety, equity, and transparency. The development of HealthRules® Payer AI aligns with the emerging guidelines of the Coalition for Health AI (CHAI) and incorporates the Artificial Intelligence Risk Management Framework (AI RMF 1.0) published by the National Institute of Standards and Technology (NIST).

This governance model ensures that while health plans benefit from innovation, they remain protected through:

  • Collaboration: Fostering partnerships with stakeholders to align solutions with evolving needs.
  • Ethical Standards: Dedication to enterprise AI risk governance regarding bias, privacy, and fairness.
  • Operational Value: A focus on features that generate measurable business outcomes.

Advanced Capabilities: Agentic and Generative AI

HealthRules® Payer AI leverages cutting-edge definitions of AI to deliver specific business value. The platform integrates Agentic AI—systems designed to operate autonomously and solve multi-step problems—alongside Generative AI for content creation.

Key features include:

  • Claims Summarizer & Process Agent: Automating complex claims workflows.
  • Configuration Assistant & Optimizer: Enhancing system setup and efficiency.
  • Unstructured Data Automation: Extracting value from complex data sources.
  • Chatbot Assistant: Improving engagement through natural language processing (NLP).

By deploying these agentic services, health plans can achieve goals through systems that demonstrate autonomy, adaptability, and reasoning, ensuring they are positioned to address both today's challenges and future industry changes.