GuidingCare Appeals & Grievances

HealthRules Payer is even more powerful when combined with GuidingCare®. Our unique Care-Payer Data Exchange solution provides the API-based integration that enables the continuous management of member care and core administrative processes.

Care-Payer provides a range of vital capabilities, including:

• Standardized core data delivery from HealthRules Payer to GuidingCare
• Authorization entry workflow improvement, including single-case agreement and referral category enhancement
• Near-real-time authorization delivery from GuidingCare to HealthRules Payer

Most notably, Care-Payer includes Benefit Predictor integration. This unique feature enables GuidingCare users to quickly and easily answer complex benefit questions prospectively from members and providers.

This Benefit Predictor integration is incorporated into several key workflows, giving Utilization Management staff and care managers unparalleled access to near-real-time benefits information.

Care-Payer Data Exchange delivers significant benefits to your organization, including:

• Smooth implementation through HealthEdge expertise and standardized processes
• Synchronized data sets between HealthRules Payer and GuidingCare
• New levels of operational efficiency in authorization entry and medical management
• Improved payment integrity
• Certified data exchange

HealthEdge Care-Wellframe is a scalable, flexible integration that brings together Wellframe and GuidingCare, our full-spectrum care management platform, into one unified solution that offers health plans a comprehensive package with the right tools to transform their care management function.  

The Care-Wellframe integration enables health plans to: 

• Streamline Care Management Workflows: A fully integrated solution provides care managers with a comprehensive member view through a singular care management platform – no more swivel chair. 

• Enhance Member Engagement: Meet members where they are on their own terms through omnichannel communication and a multi-modal digital front door. 

• Scale Care Management Resources: Maximize care manager efficiency and support more members with dynamic decision support tools, alerting logic, and instant access to clinical and community SDOH resources. 

With Care-Wellframe, health plans unlock the power to revolutionize care management operations and elevate member outcomes through a seamless, unified solution designed for impact and scalability.