HealthRules Payer is a next-generation Core Administrative Processing System (CAPS) designed to modernize and transform health plan operations across various sizes and lines of business.
Product Overview & Key Benefits It serves as the core platform for managing critical operations such as claims processing, benefit configuration, member enrollment, and provider contract management. The platform is built on a modern, cloud-native architecture that enables superior resiliency to market and regulatory changes. Customers regularly achieve high auto-adjudication rates (up to 90%) and financial accuracy (up to 99%), significantly reducing manual processing and administrative costs. Its core value proposition is its ability to quickly adapt to new business models, including value-based care, and rapidly bring new products to market.
Main Features & Capabilities
- HealthRules Language™: A patented, English-like rules engine that allows business analysts to configure virtually any benefit plan or provider contract logic without writing custom code, enabling rapid configuration (reducing time from months to hours for some changes).
- Real-time Claims Adjudication: Automated, high-accuracy claims processing with auto-adjudication rates up to 90%.
- HealthRules Answers: A business intelligence solution that provides real-time access to operational data for reporting, analytical dashboards, and informed decision-making.
- HealthRules Connector: A robust, API-based integration layer that provides real-time and batch access to all HealthRules data and functionality for seamless integration with other systems.
- AI-Powered Automation: Leveraging AI to streamline configuration, automate rules-driven processes, and enable AI-assisted decision-making.
- Web User Interface: A modern, intuitive, and browser-based experience that eliminates the need for desktop installations and supports a cloud-native architecture.
Target Users and Use Cases The software is targeted at health plans of all types and sizes, including small, midsize, and large enterprises. Primary use cases include Claims Processing and Adjudication, Benefit Plan Design and Configuration, Provider Network Management and Contracting, Member Enrollment and Eligibility Management, and enabling the transition to Value-Based Care Models.