HealthRules Edge Core Administrative Processing System
HealthRules® Edge, formerly HealthRules® Payer, is our core claims engine: a cloud-native solution that powers accurate, efficient claims administration, delivers industry-leading auto-adjudication rates, and enables stronger financial and operational performance.
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What Sets HealthRules Edge Apart for Health Plans
HealthRules Edge powers accurate, automated core administration across the health plan enterprise — for operations, finance, and technology teams alike.
HealthRules Edge AI-Embedded Modern Core Administration
Power accurate, efficient claims administration for home and host health plans. HealthRules Edge delivers industry-leading auto-adjudication rates and stronger financial and operational performance.
- 90–97% first-pass auto-adjudication
- 99%+ payment accuracy
- Lower administrative costs
- Scalability without added headcount
Easy Benefit and Rules Configuration
Quickly and accurately configure virtually any benefit plan, provider contract, or other core business process.
- 90–97% first-pass auto-adjudication
- Patented, English-like HealthRules Language enables business-led configuration with 98% accuracy
- Fewer manual touches so teams can focus on members
Real Time Data Insights
Fully integrated, robust analytics enable actionable insights to improve patient outcomes, lower costs, and increase transparency inside and outside the health plan.
- Next-generation business intelligence
- Comprehensive data warehouse
- Capabilities to spot trends, correlations, and root causes
- Ability to identify new market opportunities and validate new products
Guaranteed Operational Outcomes
Drive new levels of speed, automation, and accuracy with our innovative operating models.
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Vendor consolidation and integrated ecosystem drive volume-based efficiencies
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Guaranteed Per Member Per Month (PMPM) savings with Enduring Edge BPaaS model
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Outcomes guaranteed in contracts: cost savings, precision gains, accelerated time to value with Enduring Edge BPaaS model
HealthRules Edge's AI-Embedded Claims Engine
HealthRules Edge embeds AI directly into claims workflows, not bolted on top, delivering industry-leading auto-adjudication rates and stronger financial and operational performance.
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Real-time adjudication
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Embedded AI agents
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Straight-through processing
HealthRules Edge enables Real Time Data Insights
Fully integrated, robust analytics enable actionable insights to improve patient outcomes, lower costs, and increase transparency inside and outside the health plan.
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Next-generation business intelligence
-
Comprehensive data warehouse
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Capabilities to spot trends, correlations, and root causes
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Ability to identify new market opportunities and validate new products
Cloud-Native Integration
Open, enterprise-class API's connect HealthRules Edge to your ecosystem with always-current releases.
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API-first architecture
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Ecosystem connectivity
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Continuous updates
HealthRules Edge Suite
HealthRules Answers
HealthRules Answers is the real-time business intelligence solution for HealthRules Edge — turning claims, financial, and member data into insight health plans can act on.
HealthRules Connector
A robust integration layer linking HealthRules Edge seamlessly to your ecosystem, allowing plans to analyze current business situations, identify trends and opportunities and enjoy unparalleled transparency.
HealthRules Promote
HealthRules Promote is a configuration and promotion application to more accurately launch products and benefits faster, with less risk and less IT dependency.
HealthRules Edge for Home & Host Plans
HealthRules Edge offers built-in capabilities for home and host plan claim processing, enabling strengthened resilience, accelerated growth, and superior operational excellence.
90–97% First-Pass Auto-Adjudication
"HealthRules Edge customers regularly achieve 90–97% first pass auto-adjudication and 99%+ payment accuracy - with 6 of 9 national health plans running on HealthEdge."