Solutions
A Suite of Solutions That Deliver Value - and a Path Forward
HealthEdge® delivers an entire healthcare ecosystem, providing you with one set of healthcare solutions to manage all your complex needs and prepare for the future. Deployed individually or in combination, these healthcare solutions deliver what health plans need to succeed in an ever-changing market while ushering in the future of healthcare.
Data & Analytics
HealthEdge
Claims
EHR
Benefits
Member
Contracts
Gaps in Care
Third Party
Federal/State
INTERNAL TO PAYER
What if my plan benefit designs, reimbursement terms, and payment policies were managed in an integrated ecosystem?
INTERNAL TO PAYER
What if you could set up a new line of business in a day?
PROVIDERS
What if you could tell your patient their out-of-pocket costs in real time and manage your billing?
INTERNAL TO PAYER
What if I could manage hundreds of configurations instead of thousands to pay claims accurately?
INTERNAL TO PAYER
What if my plan could achieve >97% AAR and payment accuracy?
MEMBERS
How can I be supported in my healthcare journey after I leave my doctor's office?
INTERNAL TO PAYER
What if I could rapidly model the impact of new potential benefit contracts?
INTERNAL TO PAYER
What if you could set up a new benefit plan in an hour?
PROVIDERS
How can digital tools help patients' health journey between visits?
HealthEdge Solutions
Core Administrative
Processing System
HealthRules® Payer is the industry's leading, digital, next-generation claims administration processing system designed to deliver agility, automation, and accuracy for health plans of all sizes. It streamlines operations, reduces costs, and enhances experiences for providers and members, all while adapting to evolving consumer, regulatory, and market demands.
HealthRules Solutions Suite
Care Management
GuidingCare® is a care management solution that enhances coordination, communication, and member engagement. It empowers patients to manage chronic conditions while streamlining processes with tools for utilization management, appeals, and population health. Features like a provider authorization portal, built-in analytics, and network integrations provide the connectivity and insights needed to improve healthcare delivery.
GuidingCare Solution SuiteProspective Payment Integrity & Accuracy
HealthEdge Source™ is an advanced payment integrity solution combining claims pricing, editing, and analytics in one platform. It ensures accurate claims processing, clear audit trails, and seamless integration with HealthEdge and third-party systems, reducing waste and enhancing efficiency in operations.
Source Solutions SuiteMember Engagement
Wellframe™ is a digital member engagement solution that strengthens connections, delivers actionable health insights, and improves satisfaction and outcomes. With digital health tools, care navigation programs, and seamless ecosystem integrations, it empowers efficient operations while meeting modern healthcare needs.
Wellframe Solution SuiteProvider Data Management
HealthEdge Provider Data Management is a cloud-based solution designed to streamline provider data management, ensuring data integrity, accuracy, and quality across health plan operations. By reducing inefficiencies and optimizing workflows, it enhances performance and enables health plans to deliver superior care with confidence.
Provider Data ManagementCare-Payer Integration
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 benefits information.
Learn MorePayer-Source Integration
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 can help improve payer-provider relations and member satisfaction.
LEARN MOREServices
Professional Services
Gain the capabilities to be a next-generation health plan – swiftly and surely – with the expertise and support of HealthEdge Professional Services.
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Customer Success
If you’re seeking guidance on how best to proceed, the HealthEdge Customer Success team can act as your business partner, working closely with you to understand and anticipate your present and future requirements.
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