The HealthRules Solution Suite

HealthRules® Payer

Core Administrative Processing System (CAPS)

Many health plans continue to rely on legacy Core Administrative Processing Systems (CAPS) as the backbone for managing critical operations such as claims processing, benefit configuration, and member enrollment. However, these systems were not designed to meet the complexities of modern healthcare. A modern CAPS solution like HealthRules Payer doesn’t just solve immediate operational inefficiencies—it empowers health plans to build an integrated technology ecosystem, thrive in complex markets, and stay ahead of the competition.

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It’s been easy to enter claims and add more members since implementing HealthEdge’s HealthRules Payer. We don’t have to add data manually and because it’s scalable, reporting has gotten a lot better, quicker too. Our staff can now obtain the information and data they need to do their jobs so we’re much more efficient.

— Sara Mavredes, VP Business Information and Operations, McLaren

Features

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The HealthRules Language™

The patented HealthRules Language is English-like, enabling you to quickly react to market changes and new opportunities through fast and accurate configuration and easy construction of new products and benefits.

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HealthRules Answers

HealthRules Answers is a business intelligence solution that provides access to operational data from the core administration processing system for reporting and analytical dashboards. Users can see and share metrics with stakeholders immediately to enable informed decisions at the point of care.

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HealthRules Connector

HealthRules Connector is a robust, enterprise-class integration layer that provides real-time and batch access to all HealthRules data and functionality. It enables you to integrate HealthRules with any other system or third-party platform that can consume real-time data.

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AI in HealthRules Payer

HealthRules Payer is leveraging AI to define the next-generation core administrative processing system with unprecedented automation, agility, and insight. By automating rules-driven processes, enabling AI-assisted decision-making, and streamlining configuration, HealthRules Payer will empower healthplans with increased efficiency, reduced administrative costs, and improved financial accuracy.

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Discover how health plans leveraging HealthRules Payer as their core administration platform solution have been able to quickly address market opportunities and stay ahead of their competition.

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What Sets Us Apart

New Business Models

Adopt the full spectrum of value-based reimbursement models. Bring new benefit plans to market and implement provider contracts quickly and easily.

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Operational Efficiency

Drive new levels of speed, automation and accuracy. HealthEdge customers regularly achieve 90%–97% first-pass auto-adjudication rates and at least 99% accuracy.

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Resiliency to Change

Embrace change, stay competitive and take advantage of opportunities created by changing market dynamics.

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Configuration Flexibility

Quickly and accurately configure virtually any benefit plan, provider contract or other core business process using HealthRules LanguageTM.

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Seamless Integrations

Enjoy more cost-effective and low-risk maintenance of your IT ecosystem by integrating with other best-of-breed systems in real time via standard APIs and integration technologies.

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Business Insights

Leverage actionable, real-time insights that improve patient outcomes, lower costs and enable transparency inside and outside of the health plan.

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Modern Upgrades

Take advantage of the latest technology innovations – easily and affordably – to incorporate new functionality frequently.

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Care-Payer Integration

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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 benefit 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
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Payer-Source Integration

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The integration between HealthRules Payer and Source creates a new level of operational efficiency and accuracy in claims pricing and editing. With the continuous management of payment integrity and core administrative processes between platforms, the Payer-Source integration enables:

  • A single source of truth
  • Increased accuracy
  • Organization-wide IT lift
  • Improved payment integrity
  • Streamlined support model

The increased transparency gained from the Payer-Source integration improves payer-provider relations and member satisfaction.

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The HealthRules Solution Suite

HealthRules Payer

HealthRules Payer provides transformational capabilities to health plans of all types and sizes with features that align with your business processes and functional areas.

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HealthRules
Answers

Our HealthRules Answers business intelligence solution transforms the way you see and use data in real time, helping to reduce costs, identify market opportunities, validate new product offerings and support next-generation business models.

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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.

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Additional Offerings

HealthRules Promote

Our Configuration and Promotion application enables your organization to benefit from increased automation, greater accuracy, a simplified process and lower costs.

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HealthRules Home & Host Processing

HealthRules Payer offers built-in capabilities to support all aspects of the home and host program, reducing complexity and eliminating unnecessary duplication of provider data.

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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.

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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.

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