HealthRules Payor
HealthRules Payor is an innovative, next-generation solution for healthcare benefits and claims administration. Built with a patented English-based rules language known as HealthRules Language (HRL), HealthRules Payor makes it easy for your organization to read, write and understand the complex benefit and provider contracting rules that drive claims processing.
With HealthRules Payor, you can respond quickly and easily with new products to address changing market demands. Innovative features such as “constant adjudication” and “versioning” change the paradigm for claims adjudication, giving your organization unprecedented levels of payment accuracy and tighter financial control. Tight integration between claims and benefit administration allows your organization to drive down costs while improving the quality of healthcare.
HealthRules Payor provides a comprehensive set of capabilities to support your entire business operation or the selected areas you are looking to improve. Click the following capabilities that interest you to learn more about them:
Group and Policy Administration
- Supports HMO, PPO, POS, Government, CDHP and custom benefit plans
- Flexible benefit plan design using English-based rules language
- Supports true member-level benefit administration
Member Management
- Efficiently handle all membership and eligibility processing
- Store COB, pre-existing condition and HIPAA PHI information
- Customize processing with member-level user defined terms
Provider Relations
- Set up complex networks and network interrelationships
- English-based rules for pricing contracts and reimbursement arrangements
- Support for National Practitioner Identifier
Claims Entry and Processing
- Efficiently process claims with high auto-adjudication rates
- HIPAA-compliant EDI entry of claims data
- Dynamic calculation of benefit accumulators
- Ability to view and understand the benefits and pricing rules used in adjudication to pay the claim
Claims Re-Pricing
- Easily manage complex, multi-tier provider networks and contracts
- Automatically vary price based on a member's product, location, etc.
- Set-up complex tiered pricing rules, inpatient stop-loss agreements, and sophisticated conditional pricing logic using easy-to-understand rules language
- Functions as a stand-alone pricing engine or as part of a complete health plan administration solution
- Includes support for HIPAA EDI transactions
Utilization Review and Management
- Rules based authorization and referral processing
- Referrals and authorizations automatically assigned to claims
Finance, Billing, and Payment Processing
- Support for CDH healthcare accounting
- Support for FSA, HRA and HSA processing
- Fund balances stored within the core repository for easy access
- Easy integration with external fund managers and financial applications
- Sophisticated member-level premium billing
- Complete claims payment processing
Customer Service
- Efficient tracking and resolution of incoming service requests create a positive experience for members, providers, employers and other important customers
- Easy access to claims, eligibility, authorizations, bills, documents, correspondence or any information in the system allows service reps to respond quickly to customer requests
- Unlimited ability to track comments ensures a complete history of the service request is always available
- On-line reports allow managers to track open issues and monitor service rep productivity
- On-line routing of service issues provides a powerful tool to enhance organizational efficiency
Integration
- Easy integration with external applications for: financials, billing, member communications, credentialing and case management
- XML integration eases implementation to comprehensive consumer portal
HealthRules Payor is the most technically-superior enterprise-class product available today. Built with the latest technologies and designed on an entirely open, service-oriented architecture, HealthRules Payor integrates simply and easily with other applications in your existing enterprise environment. Unlike alternative technology platforms, HealthRules Payor scales easily to meet the needs of organizations of any size.
HealthRules Payor consists of four integrated components:
- HealthRules™ Designer, an English-language based rules authoring environment for defining benefit plans, policies, contracts and workflows
- HealthRules™ Manager, comprehensive capabilities to automate core business functions
- HealthRules™ Server, next-generation claims adjudication engine and patient-centric repository
- HealthRules™ Connector, XML web services and application integration engine.