Core Administrative
Processing System
(CAPS)

More than ever, health plans need to differentiate themselves to maintain a competitive advantage and to thrive.

A Core Administrative Processing System (CAPS) is the central nervous system of what a health care company provides. HealthRules Payer offers you the edge, a solution purposefully designed to improve customer experience capabilities, enhance data management and data quality, with an ecosystem approach to accommodate your unique and evolving needs. Future-proof your health plan with a digitally-forward partner spearheading change in healthcare technology—let's change health care together.

Learn More

The HealthRules® Solution Suite

HealthRules Payer

With modern technologies, seamless integrations and ease of configurability, HealthRules Payer can help your health plan transform business processes and achieve higher levels of efficiency.

Explore HealthRules Payer
HealthRules
Answers

HealthRules Answers is a business intelligence solution, transforming the way you see and use data in real time, helping you identify market opportunities, explore new product offerings, and support next-generation business models.

Explore HealthRules Answers
HealthRules Connector

HealthRules Connector is a robust integration layer that links HealthRules seamlessly with other systems, partner networks and exchanges, creating a digital ecosystem enabling you to share critical healthcare information quickly, easily and securely.

Explore HealthRules Connector

Additional Offerings

HealthRules Promote

HealthRules Promote is a configuration and promotion application, empowering your analysts to focus on configuration goals and confidently deploy changes into production with ease.

Explore HealthRules Promote
HealthRules for Home & Host Plans

HealthRules Payer offers built-in capabilities to support home and host plans, enabling you to react swiftly to regulatory shifts and market changes, adopt new business models, and offer business insights.

Explore Home and Host capabilities
Machine Readable Files

The HealthRules Machine Readable Files Suite 3.x is a cloud-deployed SaaS application that improves health plans’ processes for publishing Machine-Readable Files (MRF) of their negotiated rates and allowed amounts, making meeting regulatory requirements easier, faster, and more accurate than ever.

Watch the video
Provider Data Management

HealthEdge Provider Data Management creates a single source of truth for provider data. Natively integrated with Core Administrative Processing System, Provider Data Management streamlines ingestion and enrichment using a Generitive AI-powered framework and distributes cleansed data through a configurable, event-based, realtime API architecture. This enables real-time accurate data to flow across the HealthEdge solution suite and the broader heath plan ecosystem.

Explore Provider Data Management:

FAQ

What is a "Next Generation CAPS"?

Next-generation CAPS (Core Administrative Processing Systems) are advanced technological solutions designed to modernize and streamline health plan's administrative processes. These systems address the limitations of legacy CAPS by offering enhanced flexibility, automation, and integration capabilities.

Learn More

What is HealthRules Payer's approach to integrations?

Built on modern architecture, HealthRules Payer is designed to seamlessly integrate with a health plan’s key applications within their ecosystem. HealthEdge Professional Services has led the way with successful integrations for dozens of customers with countless touchpoints.

Learn More

What is the typical implementation for HealthRules Payer?

Your HealthRules® Payer implementation requires a precise, well-planned, and efficiently executed program. The experts at HealthEdge deliver the team, knowledge, and capabilities to transform your business and create a fully integrated digital ecosystem.

Testimonials

“We wouldn’t be in business if we didn’t make a change. Not only was our legacy solution extremely clunky and hard to configure, but only a couple of people understood it, as it was not user-friendly, and it certainly wasn’t scalable.”

Sara Mavredes, Vice President of Business Information and Operations at McLaren Health Plan
Read Case Study

"We’ve been able to drive tremendous value by leveraging automation and HealthRules Payer to not only meet the challenges we face today but to set ourselves up for long-term success,"

Stacy Chalupsky, Medica's VP for Claims Operations and Payment Integrity
Read Case Study

"HealthRules Payer has a very logical, object-oriented, natural language-based configuration process, which allows us to set up our benefits and our rules very quickly and efficiently. Network and provider contracts are among the biggest challenges to manage in any claims processing platform. As the COO, I can go into the system and look at any claim’s contract configuration, and it reads just like the contract that we wrote with a provider,"

Robert Hillman, SVP and COO of Community Health Options
Read Case Study