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 MoreThe 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 PayerHealthRules
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 AnswersHealthRules 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 ConnectorAdditional 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 PromoteHealthRules 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 capabilitiesMachine 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 videoProvider 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 HealthRules Payer?
HealthRules Payer is a next-generation core administrative processing system that provides transformational capabilities to health plans of all types and sizes.
What is the HealthRules Connector?
HealthRules Connector is a robust integration layer that links HealthRules seamlessly with other systems, partner networks and exchanges so you can share critical healthcare information quickly, easily and securely.
What is a core administrative processing systems?
CAPS is a critical tool for U.S. healthcare payer business enablement, consisting of software and services that support health insurance administration and transaction processing. These solutions historically reside at the center of payer architecture, serving as the system of record for claims and, in many cases, for member enrollment, premium billing and provider fee schedules as well.
What is auto adjudication?
Auto-adjudication is the automatic process of adjudicating a medical claim between a provider or healthcare system and a health plan. A claim must go through a 20+ step process to be adjudication, auto-adjudication ensures this happens automatically without manual intervention.
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"HealthRules Payer is an excellent system. I have worked on other systems, and HealthRules Payer is the best of any that I have worked on. I speak very highly of it. The system is exceptionally configurable. It is a highly effective benefits and claims platform."
Health Plan Vice President
"For us, HealthRules Promote has been a game-changer. We are able to empower our multi-user environments with the tools they need to implement new configurations with greater confidence and fewer issues. When we recently rolled our commercial plans on to the HRP platform, we experienced zero configuration issues."