Your Opportunities

Integrated Administrative & Clinical Insights

What if you could leverage administrative and care management insights together? 


What seemed impossible is now possible. Your core administration system and care management application can work together as one, each informing the other for greater accuracy, efficiency and improved patient outcomes. It is possible to lower both administrative and healthcare costs with one set of integrated information. In the HealthRules suite of solutions, information between HealthRules® Payor and GuidingCare is always in sync because HealthRules Payor is the single source of truth and information flows seamlessly between the applications. Nurses working in GuidingCare do not have to key patient-specific information since they receive it from HealthRules Payor and prior authorizations are visible in HealthRules Payor by a call center rep. There is no need to move between systems.

UMMS's Success with HealthRules
Claims Processed & Paid Within a Week
Auto-Adjudication Rate
4 Weeks
Into Implementation, First Claim Paid
Case Study
Bringing Innovation to a Local Population

University of Maryland Medical Systems (formerly Riverside Health Plan), a start-up health plan born from the Affordable Care Act (ACA), UMMS serves primarily Medicare and Medicaid members and leverages HealthRules to benefit their business.

Other examples include:

  • A 360 degree view of the member is provided by HealthRules Payor and GuidingCare so you can see all information pertaining to the member on one screen.  This eliminates what would otherwise be the manual process of searching through claims data to piece together the pertinent longitudinal view of the patient’s history
  • The ease of usability and “basic English language” of HealthRules Payor means that a nurse can look up a claim and easily understand how it was processed. This provides accurate decision making for a clinician, which ensures an improved outcome and lower healthcare cost
  • Claims data from HealthRules Payor serves to inform care managers putting together the proper care plan for a member.  Indicators such as repeat provider visits, lack of medication adherence and missed encounters enable care managers to create the best care plan for the member.