The HealthRules Solution Suite

HealthRules® Payer

Core Administrative Processing System (CAPS)

The fact is, a Core Administrative Processing System (CAPS) today needs to do much, much more than just core administrative processing. That’s why HealthRules Payer has been ranked number one in its class among core administration platform solutions. Besides delivering 90%–97% first-pass auto-adjudication rates and 99%+ accuracy, it enables you to react swiftly to the latest regulatory shifts and competitive pressures. It opens the door to new value-based reimbursement models, benefit plans and provider contracts. And it provides business insights that improve outcomes, lower costs and increase transparency.

Get the agility you need to drive – and accelerate – your digital transformation.

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Gartner has named HealthEdge® as a Sample Vendor for HealthRules Payer in the 2022 Hype Cycle for 12 consecutive years

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Gartner sample vendor

KLAS Research named HealthRules Payer its 2022 “Best in KLAS” payer claims and administration platform

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The HealthRules LanguageTM

The patented HealthRules Language leverages an English-like vernacular to enable 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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Discover how, for more than 10 years, health plans implementing 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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Why We’re Different

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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Adaptability 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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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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